March 18, 2016

House Hearing Explores MACRA Implementation

At a March 17 hearing, the House Energy and Commerce Health Subcommittee explored efforts by the Centers for Medicare and Medicaid Services (CMS) to implement a new physician reimbursement system created through the Medicare Access and CHIP Reauthorization (MACRA) Act.

Enacted by Congress in April 2015 with overwhelming bipartisan support, MACRA repealed the flawed Sustainable Growth Rate (SGR) formula and mandated physician participation in one of two Medicare payment policies, specifically the Merit-Based Incentive Payment System (MIPS) or Alternative Payment Models (APM). Patrick Conway, MD, acting principal deputy administrator, deputy administrator for innovation and quality and chief medical officer of CMS, was the sole witness.

Conway’s opening statement highlighted how CMS is targeting spring 2016 to release the first in a series of regulations to implement key portions of MACRA. Conway reemphasized how this forthcoming regulation will more clearly define the MIPS, a modified fee-for-service program that allows physicians to earn additional reimbursement if they perform well on a variety of quality measurement policies.

Starting in 2019, the MIPS streamlines and consolidates the existing Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM), and the Electronic Health Record (EHR) “Meaningful Use” policies, along with newly created clinical practice improvement activities, into one larger reimbursement program. MACRA eliminates the statutorily mandated reimbursement penalties associated with individual quality measurement programs.

Yet, the extent to which physicians meet the requirements of these previously separate policies is now captured in a “composite score.” Determining whether physicians are eligible for payment increases or penalties depends on how their composite score compares to a performance threshold. Conway said physicians who earn low composite scores in comparison to the benchmark threshold will be subjected to financial penalties, and high composite scores will result in additional incentive payments for doctors.

Conway’s testimony also stressed that the spring 2016 MACRA implementation regulation will further define key aspects of the APM policy. Generally speaking, APMs are policies that hold providers accountable for both the quality and overarching cost of the care delivered to a population of patients. Accountable Care Organizations (ACOs), the primary care Patient Centered Medical Home (PCMH), and bundled payments are just a few of the types of APMs envisioned by MACRA. Although numerous innovative practice models are being developed and tested by national medical specialty societies, the Center for Medicare and Medicaid Innovation (CMMI), and the private sector, Conway indicated the high bar set by the MACRA statute will make it difficult for CMS to approve APMs.

Nevertheless, Conway stressed that CMS is working diligently to comply with MACRA’s statutory mandate to solicit feedback from national medical specialty societies through the entire process of developing regulations to implement the MIPS and APM policies. On October 2015, for example, CMS released a detailed MACRA “Request for Information” that prompted more than 400 health care stakeholders, including the American College of Radiology, to submit formal comments.

Despite offering a thorough account of the major tenets of the legislation in his opening statement, Conway was less inclined to provide additional details about the more nuanced aspects of the MACRA implementation effort in response to direct questions from members of the Energy and Commerce Health Subcommittee. Pointed questions about how CMS plans to define the concept of “nominal financial risk” within an APM, the anticipated length of the APM performance period, and how the agency might specifically seek to modify and streamline the PQRS, VBM, or EHR “meaningful use” program were artfully dodged. Conway, however, did ultimately acknowledge the MACRA statute provides CMS with statutory authority to make important tweaks to these existing quality measurement programs. These changes are intended to lessen the overall burden on physicians.

Because the initial MACRA regulation is still being formulated, subcommittee members did not place undue pressure on Conway to provide more detailed answers to the hearing questions. The Energy and Commerce Health Subcommittee assured Conway that CMS representatives will routinely be called to testify before their panel on ongoing efforts to implement MACRA.

For additional information on MACRA or upcoming Congressional oversight hearings, ACR members are encouraged to monitor the Advocacy in Action newsletter.