MACRA unmasked

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Josh Hirsch
Joshua A Hirsch

Joshua A Hirsch seeks to break down the Medicare Access and Chip Reauthorization Act of 2015 (MACRA) which is slated to change the face of the medical arena in the USA and “foreshadows a monumental shift from volume to value”.

The sustainable growth rate drum would beat and beat and beat…

Medicare was established as part of Lyndon B Johnson’s great society in 1965. What started largely as a safety net for the elderly, soon began to run into cost overruns. Within a decade of its inception, payments to physicians started to get limited. In a remarkable piece of legislation, the Balanced Budget Act of 1997 (BBA), the burden of balancing the federal budget was placed on providers accepting Part B payments from Medicare.

Astonishingly, the crafters of the legislation linked this sustainable growth rate (SGR) to the US Gross Domestic Product (GDP). In the years immediately following the BBA, there were no negative updates and providers were content. In 2002, the update became negative and provider fees were cut by 4.8%. So much angst was created that in almost every cycle going forward a temporary “Doc fix” was applied, but, each fix became more and more costly. In 2012, the overnight reduction that physicians faced reached 27.4%.

Healthcare providers were pleasantly surprised when a dysfunctional Washington passed the Medicare Access and Chip Reauthorization Act of 2015 (MACRA) putting an end to the dreaded SGR. The drum appeared to stop beating. But did it? The MACRA is much more than an end to the SGR.

MACRA introduced the Merit-based Incentive Payment System (MIPS) which at first glance is a continuation of the traditional US based Fee-For-Service (FFS) system. At the time of its introduction, MIPS attempted to align the disparate but existing quality programs including Physician Quality Reporting System, Value Modifier, Meaningful Use and Physician Quality Improvement. MACRA also enhanced requirements around the use of Qualified Clinical Data Registries by making them uniquely helpful for addressing compliance requirements in MIPS.

Alternative Payment Models (APMs) are designed to address the large scale challenge facing American medicine; the transition of volume to value. In order to promote this transition, multiple significant financial incentives that are beyond the scope of this article are proposed. Of note, these financial advantages would include bonus payments and perhaps, most remarkably, a different conversion factor.

The Centers for Medicare and Medicaid Services (CMS) released a proposed rule dedicated to the MACRA earlier this year and solicited comments. For policy wonks, its 900+ pages were a truly fascinating read clarifying seemingly straightforward issues eg., how many providers are currently participating in APMs. The rule created a new designation that could be challenging for “non-patient facing” neuro- and neurointerventional radiologists who clearly face patients but participate in groups that might for other reasons be so termed. Working within this challenging framework, the American Society of Neuroradiology (ASNR) has recommended that, short term, CMS limit the patient facing designation to those radiologists’ clinicians that are those providing face-to-face evaluation and management services.

Through the MACRA, CMS is hoping to expand the group practice reporting option for all MIPS categories. At first blush, this is attractive. On reflection, there are significant concerns re: how this would work in real life. For example, a group of neurologists might have multiple Tax Identification Numbers (TINs) reflecting different components of its practice. Moreover, when thinking about a group would CMS evaluate each eligible provider and combine that into a single composite score? Or, alternatively, will it look at how the group performed as a whole. For example, if a neurosurgical group has a single spine, vascular and tumor surgeon would CMS look to group performance vis-a-vis thresholds or average each individual.

One area that has drawn a lot of commentary is the actual start date for MACRA. This is particularly noteworthy in light of CMS Acting Administrator Andy Slavitt’s openness to considering alternative start dates for this programme. Put simply, many are hard pressed to understand how data collection can begin in January 2017 as was expected in the original legislation, when so few providers, groups and systems are actually prepared to do so. Proposals for delay range from months to years.

MIPS doctors will continue to receive a composite score critical to determining their reimbursement. The composite currently consists of:

  • Quality: 50% for the 2019 payment year; 45% for the 2020 payment year
  • Resource use: 10% for the 2019 payment year; 15% for the 2020 payment year
  • Advance Care Information: 25% for the 2019 and 2020 payment years
  • Clinical Practice Improvement Activities: 15% for the 2019 and 2020 payment years.

However, many details remain unclear. The percentage at risk (or possible as bonus) escalates to +/- 9%, as such, providers deserve to know the specifics of how CMS envisions this working. Remember, data collection is set to begin at the turn of the new-year.

One thing is for sure, the MACRA is much more than the SGR being permanently repealed. It foreshadows a monumental shift from volume to value. Tectonic shifts are typically disruptive. In that context, the MACRA will not disappoint. CMS is giving providers meaningful opportunities to impact this process. The author has, for example, been asked to serve on an advisory committee for Episode Based Resource Use Measures; it is great that CMS is seeking clinician expertise and input. It is our sincere hope that the seismic shifts, which are not currently fully funded, leads MACRA to a brighter future than the BBA did with the SGR. The MACRA drum will beat on….


Joshua A Hirsch is at Massachusetts General Hospital, Boston, USA. He can be found tweeting @JoshuaAHirsch