10 Things You Need to Know About MACRA

1.What MACRA is Trying to Achieve 

The Medicare And Chip Reauthorization Act is a CMS program expected to consolidate a patchwork of other value-based care initiatives such as the PQRS, VPM, and EHR incentive programs into one cohesive track. MACRA has been designed to be the CMS’ answer to triple aim care, where the goal is to align care, health, and cost to the patient’s ultimate benefit.

This program acts as a response to previous complaints that the patchwork systems were duplicative in their reporting requirements, leading to needlessly high administrative burdens on health care staff. MACRA instead only requires reporting to the CMS directly and attempts to further develop the internal validity of their reporting metrics.


2. It Will Affect All Medicare Part B Clinicians Eventually

Regardless of the other programs your patients may be participating in, MACRA encompasses them all starting in 2017. Like other programs, “eligible professionals” include physicians, physician assistants, clinical nurse specialists, and certified registered nurse anesthetists. Starting in 2019 however, this will expand to include physical and occupational therapists, speech-language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, and dietitians/nutritional professionals.

However, you may be exempt from scoring and reporting in certain criteria based on the size of your practice or you position within a larger employer such as a health group. Other options include individual physicians combining their efforts (and budgets) to report together as a “virtual group”.


3. You Need to Choose the Right Path for Your Practice

As part of the MACRA ruling, clinicians will have the flexibility to choose between two paths of value based care. Failure to meet the standards or actively participate in your elected path by the proposed deadline will result in financial penalties much like in the former PQRS program. The choice is between the MIPS program with contains elements of the PQRS, VPM, Meaningful Use programs and the APM model, that includes programs like bundled payments.

The MIPS can be viewed as the mandatory minimum, while an APM is an advanced endeavor as it includes the MIPS standards but also additional goals to be met. APMs also require that the provider bear the brunt of the financial burden of participation. It is expected that most professionals will be following the less challenging MIPS path.


4.Your Past Performance Will Impact Future Spending

The proposed ruling sets a criteria of performance metrics to determine whether you receive a bonus for providing high value care, or a penalty for wasting resources. On a bi-annual basis, providers will be given a Composite Performance Score (CPS) that reflects their score in 4 categories: quality, resource use (ie cost), advancing care information (ie EHR adoption and integration standards), and clinical practice improvement activity (CPIA). Providers will have to provide evidence that they are fulfilling the criteria for each category in order to receive points. Patient outcomes reporting is primed to be critical to such evidence, as well as keeping patients out of needless office visits by remotely monitoring them at home instead.

Outside of partnering with a digital health company, smaller practices may remain competitive by taking advantage of the weighted nature of the CPS, where depending on the details of your practice, different categories may be weighed more heavily (for better or for worse) than others because they are more applicable to your specific practice.


5.You Now Need a Digital Health Partner to Survive

Partnering with a digital health company is practically a requirement to fulfil MACRA criteria while still maintaining profitability. Not only do practices need to continue to work on EHR incentives but now they need to meet ONC IT certification for those EHR systems. For smaller practices that do not have a relationship to a large hospital network to afford a dedicated IT department, this inevitably means outsourcing these upped technical requirements to a company that specializes in them.

MACRA is especially interested in encouraging the use of remote monitoring devices and services as an effective way to stay in touch with patients along the continuum of care without incurring expensive office visits or burdening clinics with hiring extra administrative staff to manage patient out-reach.


6.All Patient Data is Reported to the CMS

Practices will be required to report patient data of both public (ie. medicare) payer patients as well as private payer patients. They plan to use this data to improve the program over time by looking at how EHR adoption could be improved, redesigning quality measures, and providing incentive for the private sector players to develop remote monitoring solutions.

This point has prompted some concerns over doctor-patient privilege and trust, especially for physicians working in behavioural health. They are concerned that such reporting will erode their patient’s trust in them, which is critical to the working relationship, and be counterproductive to their patient’s progress.


7.It Marks the End of the SGR and the Beginning of a New Fee Schedule

An advantage of MACRA is that it ends the use of the highly criticized Sustainable Growth Rate (SGR) formula that determined how the medicare budget was adjusted for each year. The SGR will be replaced with new rates that are dependant on your MACRA path.

If your practice elects for the MIPS track, the maximum bonus or penalty rate you may receive starts at 4% in 2019 when participation is enforced, and increases to 5% in 2020, 7% in 2021, and 9% from 2022-2025. After 2026, the annual baseline increase will be of 0.25%. Physicians may also receive an additional 10% bonus for “exceptional performance”.

For those who chose the APM track, there are no penalties due to the financial burden of participation in this track. There is however a 5% annual bonus you may qualify for between 2019-2024, followed by a 0.75% annual baseline payment update starting in 2026.


8.Results Will be Managed by the CMS

MACRA seeks to set a standard for transparency, which is reflected in the decision that all reporting and score statistics for participating providers will eventually made available to the public through as CMS regulated website. This site is anticipated to include CPS scores for health networks and individual providers along with comparisons to a national average. This seems to be the CMS’s answer to privately owned websites like Healthgrades and Leapfrog, which collect and publish similar “doctor report cards” to inform consumers of a physician’s quality.


9.Transitional Support is Available

The CMS recognizes the financial and technical burden these changes would have on clinical workflow and staffing. As such they have included a budget for transitional costs – up to $100 million towards technical assistance over 5 years to help encourage participation. This includes 29 practice transformation networks to provide peer-level support to physicians making the transition towards MACRA compliance, 10 support and alignment networks for specialty providers, and a “Health Care Payment Learning and Action Network” as a forum for small practices and other organizations to discuss, track and share best practices on their transition path.


10.Nothing is Official Until November 1st

It’s important to remember that MACRA at this time is still a proposed ruling – while it is highly likely that the 962 paged ruling will be approved and begin effect November 1st of this year, details of the ruling may be subject to change before this date. Comments were requested and received in plenty by June 27th cutoff for feedback, and many hope that the CMS takes these into consideration when they finalize the ruling.

This means that there is still time to prepare your practice. Ratchet Health can help your practice transition into these new requirements. We provide custom care paths and patient-reported outcomes measurement solutions that assist your practice in producing evidence of value to meet Quality standards and fulfil CPIA subcategories like beneficiary engagement, care coordination and population management.

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