MACRA & Medicare Payments

Experts discussed key issues concerning the “Medicare Access and Chip Reauthorization Act of 2015” referred to as MACRA at a briefing for reporters held at the National Press Club on June 30, 2016. Marilyn Serafini, President and Co-CEO of the Alliance for Health Reform with Alan Weil, Editor-in-Chief of Health Affairs  moderated the session on MACRA.

Mark Miller, PhD, Executive Director of the Medicare Payment Advisory Commission (MedPAC) explained that MACRA repeals SGR and establishes two paths for payment for clinicians.

One path would establish the Merit-Based Incentive Payment System (MIPS) and the other path would provide payments and higher updates for eligible clinicians who participate in Alternative Payment Models (APM). In order to be eligible for APMs under MACRA, the criteria states that there must be a certified EHR and comparable quality measures to MIPS.

MIPS would be for clinicians not meeting APM criteria and starting in 2019, clinicians who do not qualify as APM participants would receive provider payments for four years 2015-2019 stabilized at 5 percent annually.

So the choice is that physicians can remain in Fee-for-Service (FFS) but be subjected to payment adjustments through MIPS or physicians can participate in APMs if they qualify. However, clinicians must have a specified share of FFS revenue or beneficiaries to be eligible for an APM to qualify for incentive payments. CMS proposes to use several methods to assess clinician eligibility to maximize the number receiving an APM incentive payment.

Farzad Mostashari, CEO of Aledade, a start-up he co-founded, helps primary care doctors transform their practices and form ACOs. Help is needed for small practices since more than one-half of all family medicine physicians’ care for patients in practices with five or fewer providers so that small practices need to be able to thrive in the value environment

In today’s world, consolidation and coordination are key words that are well known. With consolidation, provider organizations will evolve from solo physician practices resulting in groups of physicians involved in a number of specialties.

Mostashari noted, “It is also expected that physicians will be hired by delivery systems that sometimes will own hospitals. As systems get bigger, they will have more control which will not necessarily improve quality or reduce costs.”

Therefore small practices could possibly form virtual groups using online technology to connect with patients and other physicians on a regular basis which would enable small practices to survive, reduce costs, and enable information sharing with the goal to ideally stay independent.

Lisa Bielamowicz, the Advisory Board’s Chief Medical Officer reports that MACRA is here to stay. MACRA does push consolidation and physicians into hospital employment, or encourages developing partnerships with local hospitals practices. Physicians will need to work with other organizations, or perhaps align with other doctors to enable the shift to a value-based model of care.

The Advisory Board reports that MACRA will affect Medicare reimbursement for not only all eligible clinicians but will also affect physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurses, anesthetists, and some other groups.

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