MACRA - A Change in Payment Methodology

Nov 10, 2016 at 03:50 pm by Staff


The Medicare Access and Chip Reauthorization Act of 2015 (MACRA) has been touted as the most significant change in Medicare reimbursement for physicians since the introduction of the Medicare program in 1965. Not only will this reimbursement change impact physician reimbursement for Medicare beneficiaries, it will establish a transformation change in the private sector as well.

Pay for performance reimbursement based on outcomes and cost reduction is not a new

concept. Accountable Care Organizations began in 2012 with CMS, and today there are 402 Medicare ACOs managing almost 8M Medicare beneficiaries. Private insurers have established Collaborative Accountable Care and Accountable Provider Organizations called "value-based arrangements." Both models are based on managing a defined patient population, and sharing the savings created by better outcomes and costs.

MACRA was signed into law on April 26, 2016 and was initially intended to replace the sustainable growth rate (SGR) formula, a flawed reimbursement methodology that was implemented to reduce CPT code reimbursement for physicians 27 percent between 2005 and 2011. The SGR reductions were never implemented due to Congress repealing the reductions each year. However, the pressures to reign in the spiraling cost of the Medicare program continued.

MACRA has two payment tracks under its Quality Payment Program (QPP). The MIPS track and the APM track. In the advanced alternative payment model (APMs) can earn bonuses annually of 5 percent. These are risk models that require significant structure, large numbers of physicians, and organization.

The Merit-Based Incentive Payment System (MIPS) consolidates three Medicare physician quality reporting programs (Physician Quality Reporting System, Value-Based Payment Modifier, and Meaningful Use of EHRs).

The majority of physicians will participate in the Merit-based Incentive Payment System (MIPS). In this track, physicians can earn plus or minus 4 percent of reimbursement in 2019, 5 percent in 2020, 7 percent in 2021 and 9 percent in 2022. Recently, CMS has indicated a delay in the implementation of the program allowing physicians to choose three different options. CMS has indicated that a final interpretation of the rules will be issued this fall.

Medicare's own projections show the vast majority of physicians in groups of less than 10 suffering penalties. That includes 87 percent of solo practitioners who can expect their reimbursement to fall, and 70 percent of physicians in groups of two to nine, Medicare data show.

Data shows 55 percent of physicians in groups of 25 to 99 can expect to see their reimbursement rise, with 81 percent of physicians in groups of more than 100 anticipated to get a reimbursement boost from MACRA. Just a snapshot of the details surrounding the new legislation.

Most physicians are unaware of the details surrounding MACRA; however, all physicians are attuned to new financial pressures coming their way.

While the details may seem overwhelming to most physicians and their staff, there is no reason to panic. Many programs are available to help physicians embrace value-based reimbursement for their Medicare, Medicaid, and private insurance patients.

The Patient Centered Medical Home (PCMH) certification and Patient Centered Specialty Practice (PCSP) certification for practices, offered by the UCF Regional Extension Center in collaboration with the IP Network, an independent physician network of 1100 physicians in central Florida, will assist physicians in positioning their practices for "value-based accountable care" programs.

It's about physicians understanding what quality measures must be monitored on patients, ensuring they collect that data on each patient, and provide coordinated care through the process, engaging the patient and care giver in all decisions. Many tools are now available for physicians that educate and engage patients through the acute and post-acute process.

Responsible accountable patient care should mean providing the right care, at the right place, at the right time, for the most affordable cost.

Independent physicians have united together in the Central Florida area under the IP Network to provide quality patient care for their patients, and address the pressures of MACRA and other collaborative care models.

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