We have entered the second year of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. It’s no secret that the costs of medical care—17.1% of the U.S. gross national product compared with 9.8% in Great Britain, 10.7% in Canada and 11.6% in France—have become an overwhelming driver for change. Further, outcomes in the U.S. appear no better and frequently poorer in many categories than in most advanced societies. The U.S. healthcare system must become more efficient and cost effective.
Physicians and other health professionals have expressed frustration, anger and despair about MACRA, feeling that we have no input or control. Certainly, this is no time to be a Pollyanna. However, MACRA could function as a springboard for changes that address fundamental financial and care activity problems that we experience in rheumatology. We need to focus on what we aspire to do best: Provide the highest quality care to our patients in the most efficient, cost-effective way possible. MACRA is the current requirement, which we can try to use as a tool to improve patient outcomes.
What It Is
MACRA quite simply is the legislation that defines the formula by which 400,000 healthcare professionals are paid for services provided to Medicare beneficiaries. It replaces Congress’ 1997 Balanced Budget Act, which determined the budget for Medicare Part B to ensure that yearly increases did not exceed the growth in gross domestic product. Implementation of that Act included a yearly Sustainable Growth Rate (SGR) adjustment to provide for formula variations, the so-called doc fix, in order to maintain adequate reimbursement to providers. However, by 2014, the SGR adjustment would have resulted in a 24% cut in Medicare reimbursement for physicians, which might have led many physicians to leave the program and was not actually sustainable. Hence, MACRA was passed with strong bipartisan support.
MACRA is not part of the Affordable Care Act; although there may be changes, it is the current policy of the Centers for Medicare and Medicaid Services (CMS) for reimbursement. We must do our best to adapt.
MACRA mandates a dramatic departure from SGR to a system that is value-driven by quality and is determined by patient care measures. The MACRA model, called the Quality Payment Program, assigns each participating healthcare professional a numerical score based on a formula of measures provided by the CMS, which include healthcare expenditures (costs) that are directly attributed to that professional’s services.
