July 27, 2018

House Subcommittee Hears Mixed Review of MACRA

Four physicians testifying before the House Energy and Commerce Health Subcommittee on July 26 offered mixed reviews regarding the Centers for Medicare and Medicaid Services’ (CMS) efforts to implement the Medicare Access and CHIP Reauthorization Act (MACRA).

Witnesses testifying before the Energy and Commerce Health Subcommittee included:

  • David Barbe, MD, immediate past president, American Medical Association
  • Frank Opelka, MD, medical director of quality and health policy, American College of Surgeons
  • Parag Parekh, MD chair, government relations committee, American Society of Cataract and Refractive Surgery
  • Ashok Rai, MD, chairman of the board, American Medical Group Association
  • Kurt Ransohoff, MD, chairman of the board, America’s Physician Groups

Enacted in April 2015, MACRA sought to advance a long-standing policy goal for Congress, specifically curbing Medicare spending through incentives for physicians to abandon the current volume-driven fee-for-service system in favor of value-based, coordinated care models. To achieve this important objective, MACRA repealed Medicare’s flawed Sustainable Growth Rate (SGR) policy and provided physicians with an annual 0.5 percent update starting in July 2015 through 2019. In addition, the legislation provided physicians with two options for receiving value-based Medicare payments, specifically participation in either the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs).

MIPS is a modified fee-for-service program that allows physicians to earn incentive payments based on achievement related to quality metrics and clinical outcomes measures. To reduce the burden on physicians, MIPS streamlines and consolidates the existing Physician Quality Reporting System (PQRS), Value-Based Purchasing Model, and Electronic Health Record “Meaningful Use” program, along with newly created clinical improvement activities into one larger reimbursement program. The recently released Calendar Year 2019 Quality Payment Program (QPP) renamed the EHR “Meaningful Use” category “Promoting Interoperability.”

MACRA also eliminated the mandated penalties associated with these previously individual quality measurement programs. Instead, physician reimbursement now depends on a provider’s “composite score,” or a cumulative assessment of a provider’s ability to meet the measures in the four individual categories in comparison to a program-wide performance threshold set by CMS. Low composite scores in comparison to the quality threshold result in physicians receiving financial penalties, while high composite scores translate into additional incentive payments. The incentives and penalties are capped at four percent in 2019, five percent in 2020, seven percent in 2021, and nine percent in 2022 and beyond.

To achieve the goal of driving expansion of value-based, coordinated care, MACRA stipulates that physicians who participate in an advanced APM are exempt from the MIPS program and eligible for five percent annual bonuses between 2019 and 2024. To be eligible for the bonuses, participating physicians are also required to derive a significant portion of their revenue from an APM. The revenue threshold gradually increases over the 10-year budget window for the policy. Because APMs require physicians to assume two-sided financial risk, or responsibility for excess costs or savings associated in relation to certain pre-established benchmarks, the quality assurance requirements are far less stringent in comparison to MIPS.

Although the Energy and Commerce Health Subcommittee received high praise for helping enact MACRA and repealing SGR, each witness implored Congress to push CMS to approve more physician-developed advanced APMs. The providers universally panned CMS for recently rejecting all physician society-developed APMs recommended for further testing by Physician-Focused Payment Model Technical Advisory Committee (PTAC). Without ample APMs, all physicians, especially specialists, are largely forced to remain in MIPS.

In addition, the witnesses thanked the subcommittee for advancing provisions included in the Bipartisan Budget Act of 2018 (BBA18), that proactively address select MACRA implementation issues. In particular, BBA’18 does the following:

  • Grants the secretary of Health and Human Services (HHS) three additional years to set the composite score using thresholds other than the mean or median;
  • Permits greater flexibility to adjust the percentage amount the “cost” performance category contributes to a physician’s composite score;
  • Removes spending on Part B drugs from the MIPS composite score calculation; and
  • Authorizes the MACRA-created PTAC to provide technical assistance to stakeholders regarding APMs submitted for consideration.

The American College of Radiology (ACR) strongly supported and encouraged Congress to enact these changes in the BBA’18. 

During the question and answer portion of the hearing, each witness roundly rejected a recent recommendation from the Medicare Payment Advisory Commission (MEDPAC) to scrap MIPS in favor of a new Voluntary Value Program (VVP). Under the VVP, clinicians participating in fee-for-service Medicare could elect to be measured as part of a voluntary group and quality for a value payment based on their group’s performance compared to a set of population-based measures. Witnesses also criticized MEDPAC’s recommendation to rebalance the fee-for-service system principally by shifting $500 million currently earmarked for the MIPS exceptional performance bonus pool either to primary care physicians or to encourage engagement in Advanced APMs. The ACR views both MEDPAC recommendations as severely flawed.

Finally, Drs. Rai and Ransohoff warned the subcommittee that high-performing physicians in MIPS are not receiving adequate reimbursement increases due to the fact that CMS exempts hundreds of thousands of physicians from the MACRA to lessen the program’s burden on small and more rurally based practices. Subcommittee Republicans and Democrats both expressed concern that only about 40 percent of Medicare physician population participates in MIPS. They vowed to get more clarity from CMS to determine if the broad exceptions process is undermining MACRA’s potential for success.

The ACR continues to monitor Congress’s efforts to oversee MACRA implementation. Radiologists are urged to look to Advocacy in Action e-News for the latest developments.