How to Survive MACRA

What Is MACRA?
MACRA restructures physician reimbursement by creating the Quality Payment Program, a framework with two pathways: the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs).

Through Jan. 1, 2019, doctors will see an annual baseline Medicare payment increase of 0.5%. These automatic increases end on that date, when MACRA begins and physicians must choose to seek reimbursement through MIPS or through an APM. Benchmarking begins much sooner.

“Even though reimbursement in the MACRA system starts in 2019, your practice is being measured beginning in January 2017,” says rheumatologist Doug White, MD, chair of ACR’s Committee on Rheumatologic Care. “Time is of the essence.”

MIPS consolidates quality measurements into a single payment adjustment. Physicians receive a composite quality score for each reporting period that is used to determine reimbursement rates, based on four performance categories—quality, advancing care information, clinical improvement activities and cost.

In Year 1, 50% of the score is based on quality, which CMS says hinges on six measures from a range of options tailored to specialties. Advancing care information makes up 25% of the score and takes into account how clinicians use technology in their practice, with an emphasis, the CMS says, on interoperability and information exchange. Care coordination efforts are included among the clinical practice improvement activities that define 15% percent of the MIPS score, and cost makes up the remaining 10%, which is based not on physician reporting but on billing claims.

Dr. Herzig believes “the whole goal is to make doctors responsible for the costs of the system.” That is the basis for concern among some rheumatologists. “When you think about the costs of care, in rheumatology, the best drugs are biologic agents, and they are very expensive,” he says. “If those drugs are rolled into the costs of care and, at some point in time, we are responsible for the costs of those drugs, too, that would be impossible. We have to see what CMS includes in resource use.”

Although MIPS does not require physicians to assume risk, it is budget neutral and by 2022, payment adjustments will range from –9% up to 27%. It is based on every physician working under a single tax identification number.

“For every person above, there is someone below,” says Dr. Herzig. “You are measured against all of your peers, so in my opinion, it’s a zero-sum game. You can be in the upper half and make money, but you’re still competing against your colleagues and all others being measured.”