MACRA, the current framework for Medicare physician payments, specifically quality incentive payments, took effect January 1, 2017. The 2015 law replaced the flawed SGR (sustainable growth rate) reimbursement formula in a rare show of congressional bipartisanship, and the implementing regulations were finalized in late 2016. Before the final version was published, CMS received thousands of comments, went on a “listening tour” and conferred with members of congress who sought some revisions on behalf of their various constituencies. A high level outline of the final rule was posted by the former acting Administrator of CMS, Andy Slavitt on the day it was published.

MACRA is a value-based payment rule which lays out potential penalties and bonuses that start small and eventually ratchet up to 9%, with additional bonuses available for top performers, subject to budget neutrality provisions of the rule. The measurement period began January 1, 2017, and the first payment adjustments will be effective in 2019, based on 2017 experience reported in early 2018. The two tracks under MACRA are the Merit-based Incentive Payment System (“MIPS”) and Advanced Alternative Payment Models (“APMs”). Together, they are known as the Quality Payment Program, or QPP.

The final rule allows for greater flexibility in implementation than was laid out in the proposed rule. For example, under MIPS in 2017 (MIPS, in general, is open to all clinicians participating in Medicare, and is easier to navigate), eligible providers may choose which measures they would like to have measured (rather than being judged on performance against all applicable measures), and they may choose a reporting period as short as 90 days (rather than the entire calendar year). Of course, these choices have consequences; earning the full bonus requires fuller reporting as well as appropriate performance, but not participating at all in 2017 would mean an automatic 4% penalty, which would be assessed in 2019.

If a substantial portion of a physician’s or practice’s Medicare reimbursement is received through Advanced APMs, the provider is exempt from MIPS and has different reporting and risk sharing requirements.

CMS lays it all out for providers on its new QPP website.

For those providers already participating in an ACO, the Advanced APM pathway is the most likely way forward under MACRA. At the time of this writing it remains to be seen whether or how the legislation creating or enabling ACOs and other Advanced APMs may change, and how such changes will affect the implementation of MACRA vis-a-vis APMs.

However, most providers do not participate in Advanced APMs and will be proceeding under MIPS, which poses its own set of challenges. For a variety of reasons related to MACRA, it is worth considering whether the administrative effort required for tracking and reporting may be harnessed for other purposes simultaneously, in order to help practices score well in the various domains of measures that will be tracked as part of the MIPS program:

  • Quality (replaces PQRS)
  • Improvement Activities (new)
  • Advancing Care Information (replaces Meaningful Use)
  • Cost (replaces Value-Based Modifier)

One observer suggests several strategies that are valuable on their own and are also likely to improve a practice’s scoring on these metrics:

  • Implement a chronic care management (CCM) program. The CCM program sounds good in theory: being paid to proactively manage patients with multiple chronic conditions makes a great deal of sense – for the patient (better care), for the practice (better reimbursement for doing the right thing), and for the program (improved efficiency and effectiveness of care). However, its rollout has been plagued with difficulties. Even a significant revision to the regulations has not been able to lift a significant barrier to broader utilization — the coinsurance requirement — which is statutory.
  • Expanding care coordination. Whether or not it is within the purview of the CCM program, care coordination, executed well, will deliver positive results in each of the four categories being measured under MIPS. While cost of care is not going to be figured into payment calculations for the first payment year, it is an important component of the MIPS score over time, and costs associated with a patient attributed to a practice cannot be managed without coordinating services across care settings. Information services needed to track and coordinate care will be instrumental in improving the health status of patients as well as managing the costs of care.
  • Patient engagement. There are patient communication and patient engagement elements to be tracked and reported under MIPS, so the successful practice will need to devote some resources to the implementation of communication channels that are more patient-friendly than EHR patient portals. Of course, this is not an end in itself; providers need to meet patients where they are in order to develop care plans that are meaningful to patients — and therefore more likely to be followed by patients — and in order to communicate with patients in a manner that is more likely to be integrated into their daily lives. Taking this sort of approach improves the likelihood that patients will see themselves as empowered, engaged and enabled to take a positive role in their own care.

In sum, clinicians eligible to participate in MACRA should do so. Standing on the sidelines risks significant financial penalties in the near term and in the long term, as well as damage to reputation and referrals (given the requirement that each clinician participating in MIPS will be given an overall score on a scale of 1 to 100). Clinicians need to dig into MACRA sooner rather than later.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

This post is sponsored by Isalus Healthcare. HealthBlawg retains full editorial control of all its posts.