Enacted in April 2015, MACRA repealed the flawed sustainable growth rate (SGR) formula and implemented a new reimbursement system that rewards physicians for the value of the care provided to patients rather than the total number of services administered to an individual. Starting in 2019, physicians have the opportunity to select whether they will participate in the Merit-Based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).
The MIPS is a modified fee-for-service system which consolidates and streamlines the existing Centers for Medicare and Medicaid Services (CMS) quality assurance programs, including the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), Electronic Health Record (EHR) Meaningful Use Program, as well as newly created Clinical Practice Improvement Activities, into one larger payment program. Physicians’ performance on these previously separate CMS policies will be captured in a “composite score.” A physician’s composite score measured in comparison to their peers dictates whether they are eligible for annual reimbursement bonuses or penalties.
APMs are loosely defined in the statute but are essentially CMS approved risk-based innovative care models, such as Accountable Care Organizations (ACOs), bundled payments and capitation. Physicians who participate in APMs are exempt from the MIPS and eligible for annual 5 percent reimbursement bonuses, however, they also require providers to assume two-sided financial risk.
Although eager to voice support for the SGR repeal and excited about the opportunities associated with a new payment system, each witness testified that average physicians likely have a limited understanding of the inner workings of MACRA and its potential impact on their daily practice patterns. In light of this information gap, ACP, AMA, and AAFP described the various efforts they’ve undertaken to increase physicians’ understanding of this important legislation, including developing in-depth legislative background materials, convening in-person meetings with their membership, and releasing unique resources to help physicians determine whether they should join the MIPS or an APM.
The witnesses also testified that, thus far, they’re pleased with CMS’ willingness to engage health care stakeholders on how to properly implement MACRA. Each witness indicated that they’ve already conducted numerous in-person meetings and listening sessions with agency representatives, as well as submitted detailed written comments to CMS in response to a formal Request for Information. In the coming days, CMS is expected to release the first in a series of MACRA implementation regulations. Absent the public release of this regulation, it’s difficult to ascertain whether these outreach efforts influenced CMS. Nevertheless, each witness expressed optimism that the final regulation would incorporate elements of their advocacy platform.
Despite their support for the underlying legislation, the hearing presented the physician witnesses with an opportunity to highlight ways CMS can use the forthcoming regulation to improve MACRA implementation. For example, Dr. McAneney stated that she hopes the MACRA regulation:
- Simplifies and standardizes the different performance measures used within the MIPS quality assurance programs
- Develops a clear pathway for approving physician developed APMs that doesn’t overemphasize the concept of nominal financial risk
- Clarifies how frequently physicians will gain access to important performance data
Many witnesses also expressed a strong desire for CMS to simplify the EHR meaningful use program while simultaneously focusing more on achieving the elusive goals of permitting greater data interoperability and preventing information blocking.
Physician representatives from ACP and AAFP also used the hearing to emphasize their desire for CMS to issue a MACRA regulation that properly values the role of primary care within the health care reimbursement system. Both Drs. Wergin and McLean touted support for the patient centered medical home (PCMH) and the newly announced Comprehensive Primary Care Plus (CPC+) model qualifying as MACRA APMs.
Background information regarding the CPC+ model can be found in a recent AIA article.
Finally, Dr. Bailet’s written testimony expressed support for Congress softening provisions enacted via the Bipartisan Budget Act of 2015 which lowers reimbursement for services delivered in newly constructed or acquired hospital outpatient department down to the level provided for care delivered in a physician’s office.
The American College of Radiology (ACR) is pleased that Congress continues to closely monitor the effort to implement MACRA. ACR members are encouraged to monitor the Advocacy-in-Action newsletter for additional information on future Congressional hearings and the forthcoming CMS MACRA regulation.