With the media focusing on the divisive healthcare debates in Congress, it is important to remember the areas of the debate that garner unanimous bipartisan support. One such area was the Medicare Access and CHIP Reauthorization Act of 2015 bill (MACRA), which passed in the Senate 92 to 8 and in the House of Representatives 392 to 37. Additionally, the Trump administration has indicated that they will continue the trends promoted by the MACRA bill to transition Medicaid and Medicare to value-based care.
Efforts to control Medicaid and Medicare spending resulted from the Balanced Budget Act of 1997 that sought to keep growth in spending below the GDP growth rate. The Sustainable Growth Rate (SGR) models they created were quickly deemed unsustainable, and spending per beneficiary increased significantly faster than GDP. Congress began in 2003 to make a regular “doc fix” to mitigate the effect of the SGR. Instead of addressing the SGR directly, Congress simply repeated their “doc fix” efforts 17 times through 2014 before finally beginning work on MACRA.
While MACRA is primarily concerned with Medicare, it has significant overlap with ongoing efforts to promote value-based care for Medicaid as well. Areas affected by the MACRA bill that have overlap with Medicaid include:
- The Quality Payment Program’s two reimbursement track options
- Updates to the Physician Fee Schedule (PFS)
- A new Technical Advisory Committee for assessing Physician Focused Payment Model (PFPM) proposals
- Incentive payments for participation in Alternative Payment Models (APMs)
MACRA replaces the SGR with annual 0.5% payment increases for each of the next five years, and gives providers two payment track options after that. These payment tracks were created under the Quality Payment Program section of the MACRA law. The two options are:
- Merit-Based Incentive Payment System (MIPS)
- Alternative Payment Models (APMs)
While an earlier blog article has already discussed APMs in detail, MIPS (Merit-based Incentive Payment System) have not yet been addressed. MIPS have similar application for Medicaid professionals as they are currently available for voluntary enrollment. They combine three existing initiatives focused on quality—Meaningful Use (MU), the Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBPM). These initiatives have been combined into a single program that CMS will use to calculate a cumulative assessment score to determine physician reimbursement changes. The score itself is based on four categories:
- Resource Use
- Meaningful use of certified electronic health records (EHR) technology
- Clinical practice improvement activities
Those able to participate in MIPS include:
- Physicians, which includes doctors of medicine, doctors of osteopathy (including osteopathic practitioners), doctors of dental surgery, doctors of dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors
- Physician assistants (PAs)
- Nurse practitioners (NPs)
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Any clinician group that includes one of the professionals listed above
Understandably, confusion exists amongst physicians about the implementation of these new systems, particularly in smaller and rural practices. Black Book Research found that 69% of practice managers were aware that to participate they need to report on six quality measures, but a mere 22% were aware they can choose the metrics best reflective of their practice’s strengths. A full 94% were unsure how to predict their 2017 scores under the new MIPS reimbursement track. To find strength in networking, 67% of small practices are considering joining an ACO.
To help with a smoother transition, members of the GOP Doctors Caucus in Congress are listening to the concerns and making plans to address them. For example, they modified some rules to be optional for smaller and independent practices during the first year of their overall MACRA implementation. Caucus Chair Phil Roe, MD (R-Tennessee), said in an interview with Medical Economics “I believe all options should be on the table to ensure MACRA is implemented in a way that benefits patients and keeps providers—particularly those in small practices.”
CMS recognizes the changes happening now are significant. They continue to go slow in their implementation and solicit feedback to find ways to streamline and reduce clinician burden, and make it easier for clinicians to participate and put their patients first. During 2017, they have engaged more than 100 stakeholder organizations and over 47,000 people to raise awareness, solicit feedback, and help clinicians prepare for participation.
Despite the myriad of measurements used to determine reimbursement schedules for participants, and additional modifications MACRA is making to the industry, many are optimistic for the future as the conversation focuses more on moving away from outdated fee-for-service models and increasing emphasis on reducing costs and improving the quality of care. Benefits of this evolving focus can already be seen by the more than 12.3 million Medicare and/or Medicaid beneficiaries who in 2017 will be served by a professional participating in the APM track under MACRA.
Additional optimism is found in remembering the primary goals of these two options available to use through the Quality Payment Program. The shared goals of the MIPS and APM tracks are to:
- Improve health outcomes
- Spend wisely
- Minimize burden of participation
- Be fair and transparent
As we continue to move forward in our efforts to evolve our efficiency, and embrace innovative programs and laws to reduce cost and improve quality of care, we can take comfort in knowing those responsible for creating and implementing these changes will have our backs and do all they can to help. CMS Administrator Seema Verma said in June 2017, “We’ve heard the concerns that too many quality programs, technology requirements and measures get between the doctor and the patient, that’s why we’re taking a hard look at reducing burdens. We aim to improve…by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”