Questions and answers about the changes coming to Medicare’s payment model
The Medicare Access and CHIP Reauthorization Act (MACRA) is a sweeping piece of legislation passed by Congress in 2015 with strong bipartisan support. While it currently only applies to Medicare Part B, MACRA is intended to gradually transform the way you are reimbursed for the care you provide all patients. The North Carolina Medical Society (NCMS) recently asked its current President, Paul R.G. Cunningham, MD, and NCMS Foundation President and former North Carolina Medical Board President Janice Huff, MD, to explain the significance of the Quality Payment Program authorized by MACRA, and outline some key decisions providers will likely face related to it.
What did MACRA replace, or is it something completely new?
Huff: For two decades Congress struggled with whether and how to implement the scheduled reductions in Medicare payments set out in this broken formula. Each year, physicians would hold their breath as legislators debated double digit reductions in Medicare payments. Finally in April 2015, Congress overwhelmingly repealed the SGR and replaced it with MACRA. This is more than just a ‘fix’ for the SGR, however. It fundamentally changes the way the government views physician reimbursement – from a fee-for-service to a value-based model – and brings some of the previous programs, such as meaningful use and the physician quality reporting system, under one umbrella called the Quality Payment Program.
Cunningham: MACRA is the mechanism that will gradually shift how we think about caring for our patients by offering reimbursement rewards or reductions based on where you are on the spectrum of change. Rather than focusing on each individual test, diagnosis or treatment provided, MACRA is pushing us toward a more holistic, data-driven approach to determine how to provide the best possible care for our patients.
Why should I care about MACRA?
Cunningham: If you ignore the framework for change set out in MACRA, there are likely to be financial penalties. Those who are part of a large system probably won’t be burdened by the nittygritty of reporting data deadlines, acquiring an EHR or even reimbursement issues because the health system will likely deal with that. For an independent, and particularly a small independent practice, the efforts to adjust will likely be far greater. In addition, regardless of whether you participate, your performance will be reported on the Centers for Medicare & Medicaid Services’ (CMS) “Physician Compare” website.
Huff: Through the NCMS Foundation’s Rural Health Initiative, we are hearing that small independent practices are struggling to understand and adapt to these changes. Luckily, there are many resources to help this group, including becoming part of a Practice Transformation Network (PTN). Through this program, the government has provided funding to offer training to help physicians, PAs and other clinicians adapt. Quality Innovation Networks (QIN) and Quality Improvement Organizations (QIO) in your community can help with data reporting. The NCMS’ website offers connections to these free resources, in the Practice Help section. Or you can call NCMS’s Solution Center (919-833-3836 x142), and get some guidance.
Will MACRA affect me?
Cunningham: Medicare will let you know if you meet the low volume threshold (defined as less than or equal to 100 Medicare patients or less than or equal to $30,000 in Part B allowed charges) and therefore are exempt from the QPP for the 2017 performance year. For most everyone else, it makes sense to begin planning now. You need to submit your data for 2017 by March 31, 2018. The first payment adjustments will go into effect on Jan. 1, 2019 and could mean up to a 4 percent increase or 4 percent reduction in fees depending on what you do. For 2017 only, CMS allows you to submit a minimum amount of data to avoid a penalty. If you do nothing, you will get a 4 percent reduction in fees.
Huff: If you do your homework now, there is no reason you should see any decrease in your payments in 2019. Since this program is designed to be budget neutral, future year payments will be maintained only if you perform at least as well as average providers.
Can I be exempt from the data reporting requirements associated with meritbased payment if I start participating in an Advanced Alternative Payment Model?
Cunningham: Some independent practices and even individual physicians may find an advantage to participating in an Alternative Payment Model such as the Next Generation ACO model or Medicare Shared Savings Program Model Track 1+. However, this does not necessarily ensure exemption from Merit-based Incentive Payment System (MIPS) requirements. Participants in an Advanced Alternative Payment Model may be exempt from MACRA reporting if certain volume criteria are met.
Huff: Making the decision to participate with an Advanced Alternative Payment Model is a very serious matter and should include advice from medical business and legal perspectives. I’ll add that deciding to join one of these arrangements does not have to mean losing independence or selling one’s practice to a health system – it can mean collaborating to build a Clinically Integrated Network designed to fulfill patient’s needs.
I’m overwhelmed by all this. Where do I start?
Huff: First, I’d educate myself by going to the CMS website:
www.qpp.cms.gov. They have information sheets and FAQs for wherever you may be in the learning process. Make sure to take a look at the guidance on obtaining additional CMS-funded assistance:
https://qpp.cms.gov/docs/QPP_Where_to_Go_for_Help.pdf.
Cunningham: CMS has great resources. The NCMS has also put together the first ‘Six Steps to Take to Prepare for MACRA’s Quality Payment Program.’ It’s on our website:
http://www.ncmedsoc.org/practicehelp/macra. National specialty societies also are excellent resources. Remember, every journey begins with a single step, and it will pay to take your first step now.
Download the "How will MACRA affect me?" flow chart below.
