Across the United States, providers are worried about changes in the way they’ll be paid under a new law.
The Medicare Access & CHIP Reauthorization Act of 2015, also known as MACRA, reforms the way Medicare pays providers who care for Medicare beneficiaries.
“Everywhere I go, every health system I speak to, [MACRA] is on their mind,” IHI President and CEO Derek Feeley recently said.
To make sense of the changes, IHI convened a panel of experts on a recent IHI Leadership Alliance call. IHI Senior Fellow and President Emeritus Don Berwick facilitated the discussion. Here’s what Leadership Alliance members learned.
How is MACRA changing payment?
Kate Goodrich, MD, MHS, Director of the Center for Clinical Standards and Quality at the Centers for Medicare & Medicaid Services (CMS), explained that MACRA replaces a patchwork collection of quality programs (including meaningful use) with a single system called the Quality Payment Program. The Quality Payment Program creates incentives for health care systems and providers to transition from payments based on volume to payments based on value.
In April of this year, CMS issued the proposed rule to implement the MACRA Quality Payment Program’s two options:
- The Merit-Based Incentive Payment System (MIPS)
- Alternative Payment Models (APMs)
Clinicians participating in MIPS will choose from a large set of quality measures that best fit the type of care they provide. They’ll have to report on six measures, instead of the current nine.
Though the law also requires that physicians be assessed on the cost of their care, Goodrich conceded there are inherent challenges in measuring costs. Consequently, she said, “the cost measures are weighted less [in the first year of implementation] than in future years.”
Of particular interest to the Leadership Alliance members, the MIPS option will also reward improvements in clinical care, such as clinical coordination, expanded patient access, and patient safety.
The other option, Alternative Payment Models, includes Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models.
In contrast, an advanced APM has additional requirements. In an advanced APM, participants must bear a certain amount of financial risk, use quality measurements comparable to those used in MIPS, and employ certified Electronic Health Record (EHR) technology.
How is CMS communicating the changes?
Goodrich acknowledged that some clinicians find existing CMS programs challenging to use.
With that in mind, efforts to educate clinicians about the Quality Payment Program will include national calls and webinars and working closely with the clinician community to answer questions and help address problems.
Goodrich recognized that it will be hard to reach all Medicare clinicians, particularly those in solo or small practices. She said that efforts are underway to identify and support smaller practices, especially where there are shortages of health care professionals, such as rural areas.
How are health care systems responding to MACRA?
Brian Vamstad, MA, Government Relations Consultant at Gundersen Health System, a member of the Leadership Alliance, described his organization’s two-pronged response to MACRA:
- Education — Gundersen is taking advantage of CMS webinars and other learning opportunities to make sure its staff fully understand the new law and leverage opportunities to improve implementation.
- Knowledge sharing — Rather than going it alone, Gundersen is collaborating and exchanging information with other organizations and stakeholders, and has benefited from studying various analyses and considering multiple perspectives.
What has Vamstad learned so far?
MACRA is going to take significant collaboration among health system departments, including IT, quality, and finance.
“How successful you are with MACRA,” he said, “will depend upon how [your organization] works together.”
How will MACRA change health care?
John D. Halamka, MD, MS, Chief Information Officer at Beth Israel Deaconess Medical Center, has been studying MACRA and talking with health IT experts.
Although he anticipates some challenges, including the problem that EHR vendors had to get CMS certified under pre-MACRA rules, Halamka is hopeful about implementation.
“With MACRA,” he said, “you’ll see much greater emphasis on patient and family engagement and data sharing between providers and patients.”
Halamka doubts, however, that large EHR vendors will be the ones providing these advancements. Instead, he believes innovation will come from “helper apps” or modules added to existing EHRs to provide additional functions.
Halamka described small, entrepreneurial companies that are creating platforms for care coordination, telemedicine, and artificial intelligence systems that read physician notes to predict their quality score.
What’s next for MACRA?
Goodrich reported that CMS is on track to finalize the MACRA regulations in fall of 2016, and is prepared to implement the program shortly thereafter.
CMS has received requests to postpone implementation, and Goodrich noted that CMS is taking concerns seriously and views the first year as a transition period.
“We want to make it easier for clinicians to be successful,” Goodrich said. “One way is to delay [implementation], but there are other ways to respond to concerns.”
Even after they issue the final MACRA rule, Goodrich vowed to maintain “a continuous feedback loop” between CMS and clinicians. “We’ll work to earn the trust of clinicians and patients.”
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Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA
More about the IHI Leadership Alliance