by Bob Doherty, MD, FACP
Over the past three weeks, I’ve had the chance to present the changes being brought by the Medicare Access and CHIP Reauthorization Act (MACRA) to audiences of hundreds of physicians—at ACP’s Leadership Day on Capitol Hill, ACP’s Board of Governors and Board of Regents meetings, several educational sessions and a news briefing at the College’s Internal Medicine 2016 Scientific Meeting, and on Saturday, to the California Medical Association’s Leadership Academy. I’ve also had chats with dozens of physicians outside of these formal presentations.
Here’s what I have learned: most physicians look at the “value-based” payment reforms being brought by MACRA with a degree of trepidation: they aren’t sure how to proceed, what measures will be used, whether they will be unfairly penalized for things outside of their control, and worried it will result in more administrative “hassles.” It is certainly true that MACRA will make significant changes in the way physicians are reimbursed by Medicare, and ACP is addressing such concerns, through our advocacy with CMS and Congress, by educating our members about MACRA and by helping them be prepared. For instance, ACP has developed a two-page explanation of the law, recommended 10 steps physicians can take right now, and developed implementation tools to help them.
Understandable anxiety and trepidation is one thing, but what worries me is that there is a growing undercurrent (just Google “MACRA will destroy private practice”) that implementation of the law will be a “sky-is-falling, end-of-medicine-as-we-know-it” type of disruption.
Frankly, this is nonsense, because MACRA offers physicians far more flexibility and choices than what that they currently have to put up with.
Remember, MACRA didn’t create the idea of linking Medicare payments to measure of value, physicians have had to report on quality measures for years, with their payments being adjusted upward (and increasingly downward) if they don’t report successfully. So the real question is, is MACRA better than what doctors currently have to put up with PQRS, Meaningful Use, and Value-Modifier programs?
- Yes, by combining reporting of quality data into one program instead of the three separate ones, MACRA can substantially ease the burden of reporting. Already, CMS has proposed a reduction in the number of measures that have to be reported under the quality program that will replace PQRS and improvements in the Advancing Care Information program that will replace the Meaningful Use program to make them less burdensome. In addition, MACRA adds a new category for reporting on Clinical Practice Improvement Activities, with approximately 90 flexible options for physicians to get credit for many of the improvements they already are making in their practices. Further, CMS has emphasized its commitment to ensuring that smaller practices get the flexibility and support they need. Although CMS’s proposed improvements don’t go far enough, ACP intends to hold the agency to its commitment to “streamlining and strengthening value and quality-based payments for all physicians; rewarding participation in Advanced Alternative Payment Models (APMs) that create the strongest incentives for high-quality, coordinated, and efficient care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system.”
- Yes, because MACRA’s maximum potential penalties for failing to successfully report quality and cost data for the next four years are less than under the current reporting programs.
Under the current PQRS, Meaningful Use and Value-modifier programs, physicians in 2017 could get a maximum downward adjustment of up to 8 percent: -2% from PQRS, -2% from Meaningful Use, -2% from the Value Modifier Program (for physicians in groups of 2-7) or -4% (for groups of 8 or more). Under MACRA, the maximum downward adjustment a physician could get in 2019 (which CMS is proposing will be based on data submitted in 2017) is -4 percent, -5% in 2020, and -7% in 2021. Only in 2022 and subsequent years would MACRA’s downward adjustment of -9% be greater than the current maximum downward adjustment of up to -8% under the current programs.
- Yes, because MACRA allows physicians to earn positive payment adjustments while the current PQRS and Meaningful Use programs only allow physicians to avoid penalties (no positive adjustments allowed).
Under MACRA, physicians can earn positive payment adjustments each year for quality reporting of up to +4% in 2019, +5% in 2020, +7% in 2021, and +9% in 2022 (although the actual maximum positive adjustments each year could be less than this, depending on how many physicians fall above or below the threshold required to avoid downward adjustments), and top performers can earn up to 10% more each year. Under the current PQRS and Meaningful Use programs, there are no positive upward adjustments available, only avoidance of penalties for failing to report successfully.
- Yes, because under the current PQRS and Meaningful Use programs, Medicare keeps the money from negative adjustments to some physicians while MACRA keeps it in the physician payment pool. Under MACRA, any negative adjustments to physicians who fall below the scoring threshold needed to get positive adjustments are redistributed to physicians who score high enough to receive positive adjustments. While such “budget neutral” redistribution creates challenges, it’s clearly better for physicians that MACRA allows the money to stay in the physician payment pool rather than letting Medicare keep it as it now does.
- Yes, because MACRA allows the thousands of physicians in certified Patient-Centered Medical Homes (or who decide to get certified) to get favorable scoring, helping them qualify for positive payment adjustments.
No such opportunity exists under the current reporting programs. CMS is proposing a number of flexible options for practices to get certified as PCMHs.
- Yes, because under MACRA, physicians in Advanced Alternative Payment Models can to earn 5% Medicare FFS bonus payments each year from 2019-24 (and more favorable updates afterwards), plus whatever payment incentives and additional revenue opportunities apply to their advanced APM.
To illustrate, CMS has proposed that physicians participating in the new Comprehensive Primary Care Plus program, which I blogged about last month, could qualify as Advanced APMs, meaning that they would get risk adjusted prospective payments averaging $15-27 each month per beneficiary, plus at risk incentive based monthly payments of $2.50-$4.00 per beneficiary per month (this portion would have to be paid back if savings weren’t achieved), plus their FFS billings, plus the 5% bonus on Medicare FFS payments available only to advanced APMs.
So yes, MACRA is a big deal, but not in the way many physicians think it is. Compared to what physicians are currently dealing with under the current Medicare reporting programs, MACRA offers more opportunities for physicians to earn positive adjustments, exposes physicians to less risk from negative adjustments through 2021, creates positive rewards for the thousands of physicians who are practicing in certified PCMHs or who choose to get such certification, keeps all of the money from downward adjustments in the physician payment pool rather than letting Medicare keep it, and creates very substantial payment rewards for physicians in advanced Alternative Payment Models. These changes are all good for physicians, especially those in smaller practices.
And, don’t forget, because of MACRA, we no longer have to deal with the annual SGR cut and all of its associated baggage.
Sure, MACRA remains a work-in-progress; more can and must be done to simplify reporting and create additional options and flexibility for physicians in all types and sizes of practice, and physicians will need help in making the necessary changes in their practices. But even as it stands right now, MACRA clearly is a change for the better compared to what physicians currently have to deal with.
Today’s question: what do you think the impact of MACRA will be on your practice?