WHAT IS MACRA?

MACRA stands for Medicare Access and CHIP Reauthorization Act. It was passed in 2015 as a bipartisan federal legislation to repeal the flawed SGR formula for calculating Medicare part B reimbursement payment rates for physicians. SGR was originally designed to control the increasing spending growth driven by the fee for service model. While it was able to limit the pricing structure, it failed because of its limited ability to control volume of services. In simple words with SGR Medicare payments to physicians might have been lower, but physicians had no incentive to order fewer tests and procedures. So came the MACRA to improve physicians and Medicare beneficiary’s payment relationship. The legislative act of MACRA comes as a package deal with provisions for funding for technical assistance to providers, funding for development of measures and testing, the requirement for data sharing and programs for it and establishing federal adviser groups. All this makes it pretty comprehensive and significant towards restructuring health care in the United States.

WHAT IS IN MACRA?

In short MACRA is a better and rewarding payment system framework for physicians for providing higher quality care to patients. How it does that?It achieves that by providing two tracks of payment

1. MIPS (Merit-based Incentive Payment System)
2. AAPMS (Advanced Alternative Payment Models)

MIPS in turn consolidates the 3 pre-existing quality reporting programs PQRS, VBPM and MUI plus adds another category to it namely Improvement Activities. MIPS determines a reimbursement plan depending upon physician’s performance by engaging the above mentioned 4 programs. Depending on their MIPS performance score health care providers will get positive, negative or neutral adjustments to their base rate for Medicare part B payment. The main principal behind MIPS is to be budget neutral. The payment for higher reimbursements for well scoring providers come from payment cuts to low scoring providers.

APMs is actually new ways for Medicare to provide for providers caring for Medicare beneficiaries. While providers participating in APMs will also be subjected to MIPs they will however receive a more positive scoring leading to higher reimbursement rates.

AAPMS is technically not a reimbursement plan and providers actually receive a lump sum amount equal to about 5% of last year fee for service payments. Physicians participating under AAPMS can get excluded from MIPS but to qualify for it they must use Certified EHR technology, report quality measures comparable to MIPS and bear the financial risk in excess of nominal amount or participate in patient centered medical home model under CMMI authority.

 

MACRA – TIME LINE – THE GAME PLAN.

Now we know who is playing and what are the rules of engagement let’s talk the time line of MACRA.

YEAR	ADJUSTMENT PERCENTAGE
2019	-4% TO +4%
2020	-5% TO +5%
2021	-7% TO +7%
2022	-9% TO +9%

 

WHAT’s YOUR ROLE IN IT?

As a provider, it is in your best interest to understand MACRA and prepare for it. MACRA ensures a value based payment system. The better the outcome of care by a certain provider the higher the percentage of payment to that provider. MACRA and its corresponding payment measures only apply to Medicare part B payments. It defines better measures to evaluate performance which results in better care at lower cost. With its more manageable and clear quality reporting measures there is less room for error in the accuracy and effectiveness.

So what does it mean for the Provider? Well as providers will be paid based on patient outcome they will actually have to look at data from multiple systems and compare themselves. This necessity will reshape the data infrastructure. MIPs data reporting will only succeed if a wide range of data is collected effectively, accurately and quickly making data sharing a key component of MACRA.

So read the rules, understand them and understand the timeline and what else???

1. Understand the performance measures and know where you stand. Compare yourself and know where you can improve.
2. Be smart and keep an eye on MAP guidelines whose recommendations are often followed by CMS.
3. MACRA is all about making things more transparent and approachable and sharing the outcomes. You will be more successful if you are more connected to other providers and plan makers and consumers.Best of luck.

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