Practice Notes

With MACRA, 2017 will be 'year of reckoning' for physician payment


Last Wednesday, CMS released its proposed rule for MACRA, the Medicare Access and CHIP Reauthorization Act, which replaced SGR and redefined parameters for Medicare physician reimbursement.

The law will fundamentally change how Medicare pays physicians and other clinicians who participate in the program. It will establish two tracks for Medicare reimbursement: one, called MIPS, for providers who are reimbursed largely through fee-for-service, and an alternative payment model (APM) track for physicians who take on a significant portfolio of APMs. In MACRA proposed rule and started to highlight implications for providers.

The rule reflects notable effort to streamline the parameters for earning Medicare payments and minimize the burden on participants, but complexity abounds, and medical groups face a compressed timeframe in which to assess options and determine their strategy. Below are five key takeaways for medical group leaders to consider as they digest the news of MACRA and start to craft their response.

1. Assume you’re in the MIPS track

  • The rule sets a high bar for APM qualification, and the most popular APMs (track 1 of MSSP, Medicare Advantage, and both of the bundled payment programs, CJR and BPCI) all do not qualify as “advanced APMs” (the term used for qualifying APMs) in the first performance year. CMS is estimating that as few as 4% of participating physicians will get paid under the APM track.
  • 2017 is the performance year for 2019 payment, so time is quickly running out to apply for new APMs that would switch your track before the start of the performance period.
  • CMS will not notify medical groups about their status for the APM track until after the MIPS performance period begins, so all but the most advanced medical groups should plan to submit data for MIPS.

2. Medical home models get a boost under both tracks

  • The rule includes strong MIPS rewards for providers participating in medical home models through the Clinical Practice Improvement category.
  • CMS also proposes creating a special pathway by which medical home models, including the Comprehensive Primary Care Plus (CPC+) program, can qualify as advanced APMs.
  • The special pathway reflects CMS’s believe that medical homes can drive value for Medicare, but medical groups must conduct their own internal assessments to determine whether existing primary care models are driving value, and if not, where changes to primary care design will yield the most benefit.

3. You can no longer afford to ignore quality reporting

  • The proposed rule holds medical groups of all sizes accountable for PQRS—not only reporting, but also performance on reported measures.
  • Many medical group leaders tell us they lack the basic infrastructure to assess performance on reported measures or determine measures to report based on current performance. To meet MIPS’ reporting and performance thresholds, medical groups must double down on building and refining their quality reporting and performance management infrastructure.

4. It’s not yet clear which alignment models will drive the most value under MACRA

  • Both the APM and MIPS tracks require strong, consistent performance on quality and efficiency measures. Those working across mixed medical staffs must carefully consider whether models like clinical integration provide a strong enough backbone to rally physicians the performance objectives stemming from this rule.

5. A lot could change between now and when the final rule is released

  • At several points in the rule, CMS asks for stakeholders to share thoughts on how to improve the current parameters. (In a notable example, the rule expressly solicits input on how to make the two bundled payment programs qualify as APMs.)
  • The stakes are high, and the rule is not yet set in stone, so the next few months present an important opportunity to participate in the comments period and share your perspective with policymakers.

This is just the beginning of our coverage on MACRA and its implications, so stay tuned. The Advisory Board will be publishing across channels about the details of MACRA, and sharing our ongoing analysis of implications for participants.

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