MACRA: Putting Together the Pieces for Practice


Be careful what you wish for: SGR and FFS will be models of the past; the success of the APM and MIPS will rely on compensation, collaboration and participation; and, to date, much remains to be done in the development of quality-based payment reform under MACRA.

Dr Timothy Laing, member of the rheumatology faculty at the University of Michigan and the senior associate chair for clinical at the University of Michigan, spoke to an audience of 40 people at the American College of Rheumatology’s 2016 Annual Meeting about implementation and opportunities under MACRA and regulation being promulgated to implement Merit-Based Incentive Payment Systems (MIPS) and the Alternative Payment Model (APM).

CMS is bound and determined to move providers from a FFS claims-based model to a quality-based, cost-contained, bundled payment methodology. Manage the risk under an APM or manage the penalties under MIPS? Inaction in 2017 will result in a payment penalty felt in 2019.

Calendar Year 2017 is a reporting year. Clinicians at a minimum must report to CMS on at least one process and one outcome measure. It may turn out that 2017 becomes a beta test year for CMS as it assesses the quality of its systems, reviews and values the data is coming in, and manages internally and externally the change management of payment reform. In 2018, CMS will provide feedback to payers and in 2019, MIPS and MACRA will likely go into full effect.

To obtain a positive performance adjustment, eligible clinicians — the formal term for participating providers in the APM and MIPS – must meet thresholds for quality; advancing care information; improvement activities; and cost containment. Cost data will be required in 2017 but it will not have an impact on the 2019 adjustment.

Eligible clinicians can elect to report as individuals or a group practice. If reporting as a group practice, all providers must report on the same measures; there is a single payment to the group.

The highest risk practices are small group practices. An individual opening a practice will receive a pass from CMS for Year One. Online tools for practices with a history of using PQRS are available now, illustrating how a given provider or practice could fare under MIPS or the APM.

To move the mountain and the providers that rely on Medicare monies will require fundamental shifts in reporting, oversight, and infrastructure for CMS and clinicians. While there is $20 million in the CMS budget to support individual and provider’s change management technical assistance, that sum does not appear to provide near enough funding.

An electronic health record and a patient registry will be critical to successful participation in MIPS or the Alternate Payment Methodology. Clinicians running a practice using an electronic health record will find the change to the MIPS or an APM less demanding. The codes for rheumatology practices follow clinical standards of practice.

Under MIPS and the APM, there remain serious concerns about attribution costs as they relate to hospital stays and drug costs, and deeply troubling is the potential that some providers will abandon high-risk, hard-to-reach, less compliant patients to their risk or penalty.

The APM will likely be limited to a small bubble of eligible clinicians, as the incentivized payment methodology requires of eligible clinicians higher thresholds of risk to participate. Most providers will be paid under the performance-based payment adjustment that is MIPS. Either way, fundamental changes to payment reform are on the horizon. Anticipate and plan now for tomorrow.

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