MACRA drives physicians toward value-based care

When Congress passed the Medicare Access and CHIP Reauthorization Act last year, it came at a time when physicians and other stakeholders were feeling intense fatigue over the numerous efforts to reform the U.S. health care system.

It wasn't any surprise then that CMS – tasked with interpreting the law and promulgating rules on how to implement it – received more than 4,000 comments over its MACRA proposal. Nor was it a surprise that more than 100,000 clinicians and stakeholders attended meetings held by CMS officials.

In the final rule, issued on Oct. 14, CMS responded to the concerns of clinicians facing immediate, steep financial penalties included in the new Quality Payment Program. CMS agreed to ease clinicians into the new program by establishing a first transition year, which allows clinicians to "pick your pace" of adoption and reporting.

But the transition year comes with promise that the program will evolve, guaranteeing that performance measurement, and the financial implications, will increase over time.

Penalties, but significant incentives too
The QPP's two tracks – the Merit-Based Incentive Payment System and the Advanced Alternative Payment Models – will cover 600,000 clinicians serving 55 million patients. That's every physician, physician assistant, nurse practitioner, clinical nurse specialist and certified registered nurse anesthetist who provides the minimum number of Medicare services (care for at least 100 patients or billing of more than $30,000 a year).

MIPS replaces disjointed physician performance and reporting programs with a single Medicare quality program. Under this track, physicians are subject to a 4 percent penalty for failing to meet minimum requirements, but the threshold for participation is pretty bare bones. Providers need only submit a few months of data to be eligible to receive small performance bonuses, but can receive larger bonuses for reporting in greater detail and receiving high marks for care quality.

MACRA went beyond just creating a consolidated quality program. It created a new approach to quality incentives, shifting clinicians out of traditional payment models altogether -- Advanced APMs.

Because of the limited scale of Advanced APMs currently in the market, this initiative is available to a smaller group of clinicians. These practitioners will receive a 5 percent lump sum bonus payment for the first five years, and will be excused from MIPS reporting requirements and payment adjustments (positive or negative).

For the past few years, value-based care models -- like bundled payments and accountable care organizations -- have focused on the providing high value care by removing fee-for-service payment incentives. Providers don't generate additional revenue by simply furnishing more care. The goal is to shift payments to the right care – those that generate better outcomes for patients.

One shortcoming of value-based care initiatives has been encouraging clinicians to commit to the new approach to delivering care. The success of value-based care is dependent on having fully engaged clinicians because they have such a high degree of direct input over the services that are ordered for patients.

MACRA, through the QPP, encourages physicians and other clinicians to take bolder steps into value-based care -- beyond quality and resource use measures -- to fully commit to participating in APMs

The new program is here, but it needs work
Quality measures leave a lot to be desired. Some are process-oriented and don't necessarily predict better outcomes – they measure boxes checked, but not whether patients get healthy. And as in all discussions over evaluating physicians, expect controversy over anything outside the control of physicians. It stands to reason that patients who don't schedule follow-up visits with their primary care physician after discharge would tend to have worse outcomes, but is that the clinician's fault?

For this program to work, CMS is going to have to get to a point where the metrics are defensible. Clinicians in the MIPS program could see payments adjust – up or down - by 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and a whopping 9 percent in 2021.

While MIPS has it shortcomings, Advanced APMs are unpredictable and currently not an option for many clinicians. There are limited opportunities to participate, based on the number of Advanced APM models, the market in which clinicians practice and the type of care they deliver. CMS will need to accommodate the influx of APM interest. The agency is already working to re-open some Advanced APMs as well as create new models to increase the options for clinicians, but time is a critical factor.

What all of this means is that, though MACRA is here to stay, there will be a roller coaster of adjustments in coming years.

Start early
Whether through MIPS or Advanced APMs, clinicians should begin to make necessary adjustments to prepare for the new programs. Value-based care models require a good deal of care delivery and operational redesign. To that extent, clinicians should begin this process early so that the learning curve isn't steep in later years when it really starts to count.

Hospitals and other APM participants will also experience the ricochet benefit of increased clinician interest in participating in APMs. Where physicians may have been too busy to engage previously, they now have a vested interest in doing so.

As the push for value-based care trickles down to the clinician level, we will see more changes to how medicine is practiced at the doctor's office. The benefit of early adoption, therefore, isn't just about getting used to new paperwork.

For this to work, and to be eligible for some of the potentially sizeable bonuses that MACRA envisions, clinicians should begin deploying tools that will help them see where the cost drivers are and how to better improve patient outcomes. Perhaps the best way to think about MACRA is the old saying about the weather in Texas. If you don't like it, don't worry, it'll change.

About the Author:
Erin Smith is the Vice President of Policy and Government Affairs at naviHealth (, and an expert on payment and delivery innovation.

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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