MACRA and the Transition to Value-Based Care

By: on September 28, 2018

With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a lot of changes are being made to Medicare reimbursements and how physicians are getting paid. Understanding those changes can be overwhelming, particularly for small and midsize medical practices.

There are clear benefits to getting on board, though: Physicians and practices that successfully transition to value-based care could see as much as a 9 percent increase in their Medicare Part B base payment rate as well as additional lump sum payments by 2022.

The incentives for participating in this new payment model are considerable, so overcoming the transitional challenges will be worthwhile in the long run.

This guide outlines MACRA’s history, benefits and challenges as well as three practical steps to take to get the most out of the value-based care model as soon as possible.

What MACRA Is, and How It Improves Medicare

MACRA is complicated. While there were a number of legitimate reasons for creating the legislation, it continues to present some challenges to physicians who accept Medicare. To understand why MACRA is complicated, it’s useful to look at how and why it came about.

Why Was MACRA Created?

To replace the Medicare Sustainable Growth Rate (SGR): The SGR was a formula implemented in 1997 as a way to limit Medicare spending on physician services by preventing the cost per Medicare beneficiary from surpassing the gross domestic product.

This formula often resulted in lower reimbursements for physicians, which in turn led doctors to stop accepting Medicare from patients. So the main reason for MACRA was to create a better system for Medicare reimbursements that would incentivize physicians to provide care for those patients.

To create two new value-based payment models under the Quality Payment Program (QPP): In 2018, providers are being assigned one of two tracks depending on their performance and history from 2017.

Those two tracks are the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APM). Both of these tracks are designed to incentivize physicians to raise the bar on patient care without raising their prices.

The purpose of transitioning to these two new payment models is to consolidate and streamline multiple value-based payment plans under one track (MIPS), while providing financial incentives to physicians willing to participate in alternative payment models.

What’s Changing for Physicians?

One of the biggest adjustments for a lot of physicians will be working through the new alphabet soup of acronyms in order to understand what’s actually different and what processes have stayed the same. Here are the highlights:

Physicians get scores for four categories under MIPS. With the exception of Accountable Care Organizations (ACOs), hospitals, patient-focused medical homes and practices that use bundled payment models, most existing practice types will automatically fall into the MIPS track. Under MIPS, practices will receive scores based on performance in four categories:

  1. Quality. Physicians will have to report on at least six quality measures, one of which must be focused on “outcomes.”
  2. Clinical Practice Improvement Activities (CPIA). Physicians will be able to select from a list of nearly 100 practice goals to aim for in order to receive rewards for improvements caused by those goals.
  3. Cost. Physicians must report on specific measures that account for specialty differentiation and claims data.
  4. Advancing Care Information (ACI). This category will effectively replace meaningful use. Physicians will generally have more flexibility, but they’ll still be expected to report on most Stage 3 measures.

The scores will be used to calculate a Composite Performance Score that will help determine whether individual physicians should receive an increase or decrease in their year-over-year fee-for-service payment.

Despite Benefits to Physicians and Patients, the Transition Creates Challenges

Many physicians are feeling the pressure when it comes to MACRA. One of the biggest challenges for implementing MACRA is the struggle to make complex changes in a short amount of time.

In fact, the actual implementation date for MACRA was nearly a year ago, which was only a couple of months after the final rule was released. Fortunately, the goal for 2017 and 2018 has so far been to introduce MACRA and collect the necessary data, so physicians still have time.

While this transition is proving to be difficult for many, there definitely are benefits to the value-based model for both patients and physicians:

  • It eliminates the Sustainable Growth Formula that was problematic for a lot of physicians. MACRA represents an effort to improve upon the flawed reimbursement method that existed before.
  • MACRA reauthorized the Children’s Health Insurance Program (CHIP), which extends funding to allow continued coverage for children of lower-income families who do not qualify for Medicaid.
  • It aims to improve patient outcomes by promoting the use of technology. By incentivizing more physicians to take advantage of interoperability, MACRA is working toward a future where collecting, sharing and analyzing patient data will be much easier to do.
  • It focuses on improving patient experiences and outcomes by relying more heavily on the results of value-based care, which rewards physicians depending on the quality of care.

Physicians Must Take Practical Steps to Ease the Transition

That limited timeline makes it imperative that physicians start taking actual steps to make this change. Here are three things you should be doing about MACRA right now.

Learn Everything You Can About What’s Changing

If you’re still trying to understand exactly what MACRA is and what changes it means for your practice, you can take advantage of professional physicians groups to find all the information you need.

Organizations such as the American Medical Association (AMA) and American Academy of Family Physicians (AAFP) offer blog posts, webinars and guides that can go into much greater detail to help physicians through this process, so using those tools will be step one.

Figure Out Your Strengths and Start Reporting Them

There are tons of different Quality Performance Measures available to choose from, and you only have to collect and report data for six of them in 2018.

Physicians and practices should spend the rest of this year looking at their list of options, determining which six measure they already excel at and start working out how they’re going to report them. According to the CMS, there are six ways participants can submit data for MACRA:

  • Electronic Health Record (EHR)
  • Qualified Clinical Data Registry (QCDR)
  • Qualified Registry
  • CMS Web Interface (for registered Groups and Virtual Groups only)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey (for registered Groups and Virtual Groups only)
  • Claims (for individuals only)

Make Sure You’re Using the Right Tools

Because so much of MACRA involves detailed data collection and reporting, you absolutely must ensure you’re using the right technology to do that.

Does your current EHR have the 2014 or 2015 Edition Certification? If not, you should update it immediately so you can start collecting the right information. Also verify that your system offers interoperability so you can share patient information securely with other doctors.

Once you’re positive your EHR is up to standard, take a look at additional tools like practice management suites and patient portals that let you better control your practice and manage your patients’ experience. Part of the MIPS score is based on quality of care, after all, so doing all you can to improve patient satisfaction will ultimately help you.

You may also like:

3 Predictions Defining the Future of Health Care Delivery in Small Practices

A Concierge Medicine Guide: Definition, Salary, and Set-Up Info

Ten Years of Technology: How the HITECH Act Influenced Physicians and EHR Adoption

Find the right tools to improve patient satisfaction