Prescription for Change

Mythbusters: MACRA edition

by Gabbie DeCuir

MACRA—the legislation that will significantly change the way Medicare reimburses physicians—is top of mind for you. We know because we've fielded over 180 MACRA questions from health care leaders in just the past two months—and we expect them to keep coming in!

These questions, along with recent member conversations, have revealed some common misconceptions about the proposed rule and its implications. Even if you're a MACRA expert, your physicians likely aren't. So to help separate fact from fiction, we've cleared up the most common misconceptions.

Myth #1: MACRA could go away under a new administration.

Reality: MACRA was signed into law by Congress and can only be abolished if Congress votes to repeal it—an unlikely event given it received bipartisan support when it was passed in April 2015. That being said, CMS has only released the proposed details of the rule, and they may adjust pieces of the legislation in the final rule. Certain elements can be modified by CMS, such as:

  • The performance period used to determine 2019 payment adjustments, which is currently proposed as 2017
  • The definition of "more than nominal risk," which determines which alternative payment models are deemed "Advanced APMs" and qualify clinicians for the APM track

Myth #2: MACRA will only affect physician reimbursement.

Reality: MACRA will affect Medicare reimbursement for all eligible clinicians, including physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurses, anesthetists, and groups that include any of these clinicians.

Myth #3: MACRA is an ambulatory program.

Reality: The payment changes mandated under MACRA impact Medicare Physician Fee Schedule payments—the fee schedule that determines the payment rates for professional services across care settings.

Myth #4: Every clinician has an equal opportunity to qualify for the APM track.

Reality: Although clinicians can choose to get involved in an Advanced APM (payment models that qualify them for the APM track), these models expose provider organizations to a significant degree of downside payment risk. Models like these should not be entered into lightly, particularly without prior experience or a robust infrastructure for managing population risk.

For those provider organizations that are ready to take on this amount of risk, time is short (if not already expired) to apply to participate in an Advanced APM before the first performance period under MACRA begins in 2017. Thus, for the most part, clinicians can assume they will start in the MIPS track—CMS predicts approximately 92% of clinicians will be in the MIPS track for the first year.

Myth #5: The MIPS penalties are higher than the penalties under current physician pay-for-performance programs.

Reality: This year, clinicians who don't meet the reporting requirements across the EHR Incentive Program, Physician Quality Reporting System, and the Value-Based Payment Modifier Program could stand to lose up to 9% of their professional payments in 2018. However, clinicians who don't meet the MIPS reporting requirements in performance year 2017 only stand to lose 4% of professional payments in 2019. This penalty will increase over time, but for the first few years, clinicians are exposed to a smaller penalty under MIPS than they are under today's pay-for-performance programs.

Myth #6: Physician groups should try to get into the APM track, because if they don't, they will be at risk for higher potential losses under MIPS.

Reality: This may not be true. Organizations that rush into an Advanced APM (such as MSSP tracks 2 or 3 or the Next Generation ACO model) without proper investment in care transformation efforts could be exposed to higher losses under that program than they would have received under MIPS, particularly in the first few years of the program.

Myth #7: Eligible clinicians should reconsider participation in MSSP track 1 because it doesn't qualify as an Advanced APM.

Reality: MSSP track 1 participants get preferential scoring under certain MIPS performance categories, which could positively affect reimbursement. Thus, participating in this model may still be advantageous.


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Find out how MACRA could make physicians even more accountable for cost and quality.

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With MACRA on the horizon and so much about it still misunderstood, physician executives should seize this opportunity to educate physicians about the program. Have another question we can help clear up? Contact your organization's Member Services representative and he or she will ensure your question gets answered.

Amid the MACRA frenzy, it's important to remember that the details aren't set in stone. CMS received over 600 comments on the proposal, so a lot could change in the final rule. Stay tuned to the Advisory Board's ongoing MACRA coverage.

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Not sure how to respond to MACRA? Check in with our MACRA Support team for expert guidance on the proposed rule and its implications.