MACRA: Enhancement of Care Quality and its chances and obstacles

By:Lori Tyler
on Nov 10, 2022

Overcoming the Medicare Control and CHIP Reauthorization Act (MACRA) problems and concerns

With the goal of providing health care providers with incentive payments based on the quality of care they offer to patients, the Centers for Medicare & Medicaid Services (CMS) have adopted multiple value-based initiatives.

The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program strengthens Medicare by helping to concentrate on the quality of treatment and keeping patients safe, the one thing that matters most. MACRA terminated the Sustainable Growth Rate model, risking future reimbursement cliffs for physicians enrolled in Medicare. The Physician Quality Monitoring System (PQRS), the Value-based Payment Modifier (VBM) and the Medicare Electronic Health Record (EHR) are components of MACRA.

The MACRA age of Medicare Access and CHIP Reauthorization Act is upon us. MACRA is here to stay, because of the continuing confusion surrounding the future of the Affordable Care Act, passed with overwhelming bipartisan support, addressing cost control and quality enhancement.

This seeming permanence means that qualifying provider organizations that have been practicing watchful waiting from the sidelines must now decide how to proceed with the Merit-Based Incentive Payment System (MIPS). 2017 is a transition year; doing something is the best approach overwhelmingly. Although non-participation would result in a negative adjustment of four percent payment, submitting something, one quality measure, one enhancement operation, or four to five advancement of care knowledge measures needed a downward change would be avoided. Partial or complete submission can result in a positive change, and a company can apply quality monitoring data for the monitoring year 2017 for as little as 90 days, which ensures that performance capture will begin as late as October 2, 2017.

Reform of MACRA Healthcare At-a-Glance

  • Ended the methodology of Sustainable Growth Rate from the determination of annual conversion factors in the payment formula for physicians’ services
  • Introduced a new approach for rewarding clinicians for value over volume based on alternative payment model
  • The Physician Quality Monitoring System (PQRS), Value-Based Payment Modifier (Value Modifier), and Medicare EHR Incentive Program (also known as Substantive Use or MU) are now simplified under the current Merit Based Incentive Compensation System (MIPS)

Allocated incentive payments for participation in alternative payment models (APMs) that are eligible

MACRA: At every level, undermining the health care system

Rebuilding the health care base under MACRA

To address the introduction of MACRA, the Deloitte Center for Health Solutions and the Network for Health Innovation Excellence (NEHI) gathered 31 senior leaders from across the health care sector, health care agencies, health plans, biopharmaceutical firms, and medical technology organizations.

Centered on a fee-for – service (FFS) basis, health care entities have developed programs. But under MACRA, those systems won’t work. It will take time to reform something as pervasive as the FSS and will raise problems for many stakeholders in health care. However, results from our cross-industry discussions indicate that many healthcare companies are ready to come together and start constructing a new foundation that is not limited by FFS rules focused on clinical delivery and payment models.

Is MACRA suitable for hospitalists?

Most structured medicine is glad to be out of the annual danger of decreases in reimbursement. The new law could, however, streamline quality reporting. But depending on your viewpoint, the precise upside depends. A hospitalist might enjoy greater upside potential with APMs, particularly for high-quality work and EHR use. However, as mentioned previously, whether it is feasible for most hospitalists to even participate in the model depends on several factors, and SHM supports the application of the law in ways that can more easily accommodate hospitalist practice and job structures.

MACRA’s Operating Requirements

Quality Measure Development Plan Operational Criteria) defines the MACRA requirements relating to this MDP and details a strategic approach to each of the following:

Applicability for Multi-Payers

MACRA needs consideration of how to implement metrics used within Medicare quality reporting services for private payers and centralized delivery systems. The development and use of payer-related measures will minimize the burden of providers and lead to better patient outcomes for increasing data collection and minimizing variance in measurement.

Strategic approach

CMS will utilize the Measure Applications Alliance (MAP), the Collaborative Core Quality Metrics, the Learning and Action Network for Health Care Payment, and other multi-stakeholder organizations to find innovative ways to streamline clinician reporting for the use of metrics through various payers and delivery networks from both the private and public sectors.

The Impacts of MACRA

Economic implications

MACRA payment will first have an effect in 2019, based on data submitted for the 2017 reporting year. In 2019, Medicare payment bonuses and fines start at + /- 4% and increase to 5%, 7%, and 9% per year until 2023.

Reputational Implications

The CMS Physician Compare website will post the MIPS Composite Score and clinician success scores. Patients or prospective business associates would be able to see and evaluate a clinician’s results. To drive the success of a healthcare practice, a good MIPS score is likely to become a significant factor.

Health technology implications

First and foremost, meaning has never been related so deeply to performance and payments before. It is important for businesses to consider how their medical technology’s proposed value aligns with the value indicators proposed within MACRA.

For physicians, there is a rare opportunity to balance

a) Commodity value

b) Patient results

c) Rewards for payment.

However, not all “value propositions” produce such a tight alignment.

MACRA for Physicians Working

Family physicians in the employed environment will need to register under MIPS unless you are involved in an AAPM. Reporting in 2017 at any stage would prevent a negative change of payment in 2019

For many factors, working physicians need to grasp the MIPS reporting requirements:

  • Final scores are linked, except for those reporting as a group, to individual national provider identifiers (NPIs). If a practitioner changes procedures between the success period and the payment year, they will adopt their new practice with any payment modifications.
  • In MIPS, performance may influence salary and compensation contracts. Physicians should be prepared to see this reflected in employment contracts because results will result in either positive or negative wage changes. A good result in MIPS could lead the doctor to greater salary / compensation.
  • The MIPS scores of practices they are considering entering should also be taken into account by physicians.

IS MACRA is a Big Problem or Big Solution

Both sides of the political spectrum applauded MACRA, and the Centers for Medicare and Medicaid Programs (CMS) was properly commended for its responsiveness to the needs of providers in finalizing the laws. However, the fact that the basic nature of MIPS tends to worsen health care inequalities without explicitly supporting lower spending or higher quality is not altered by bipartisan support and regulatory flexibility on implementation.

Problems and challenges of MACARA

With MIPS, there are 3 big problems. Second, there are very poor incentives for physicians to minimize the provision of services, and some features generate incentives to do more instead of less. No weight in the scoring is given to resource use indicators, such as total per-beneficiary Medicare expenditure. Thus, without dramatically reducing Medicare spending, providers have ample ability to seek premium increases. In addition, since MIPS bonuses are organized as premium increases rather than lump sums unrelated to the amount of Part B operation, they generate incentives for providers to offer additional services (additional treatments, examinations, imaging, office visits, hospitalizations, etc.)Particularly expensive services, because a percentage applied to higher rates yields higher revenue increases.

Challenge: High-level perspective on results

It can be remarkably challenging and time consuming to consider the overall success of a health system across a range of sites, services, and EMRs to recognize key areas of focus. A holistic view of the patient population and the full spectrum of treatment can be given by leveraging claims data. Measures with good historical performance and unique patterns at the level of a device, agency, venue, or provider can be established. Although not ideal, this will provide useful feedback for the current performance year to assess which steps are at risk or to target changes. Via targeting areas where performance is most plausible, companies will optimize ROI.

Solution: MACRA Metrics & Insights enables the consumer to imagine relative success internally and through MACRA domains in all MACRA quality assessments at the level of classes, activities, and providers.

The need for new technology for MIPS

77 percent of the physician practices surveyed of 3 or more clinicians are looking to purchase technology solutions compliant with MIPS specifications by Q4.

 MACRA rewards to improve the use of health IT by physicians

Although most providers are searching for health IT solutions to meet MIPS criteria, 92 percent of physician practices surveyed are currently not aware of any vendor innovations that support all MIPS registry initiatives for reporting in addition to their EHR for 2017.

Medicare binary sign model illustration style over black Positive small practice with MACRA

  • In order to reduce Medicare reimbursement fines or disclose all necessary data for the year to earn a small incentive, the versatile “pick your participation rate” route requires practices to disclose one successful quality indicator per provider for the year 2017. There are also choices between a single measure and all options for data reporting.
  • This versatility gives time to think about MACRA for several activities and plan accordingly. If practices use 2017 to understand the fundamentals of MACRA, they will be in a stronger place for subsequent years.
  • The exemption requirement was also reduced by CMS, so any doctor who costs Medicare less than $30,000 annually or has 100 or less Medicare patients would not have to enroll in MACRA.

Significant improvements that MACRA has brought about include:

Changed payment for services for Portion B

Many Part B providers will be subject to the Merit-Based Incentive Payment System (MIPS) beginning in 2019. Depending on the relative performance of the providers on measures relating to cost, efficiency, the use of electronic health records (EHR), and clinical development activities, MIPS payment adjustments can be positive, flat, or negative.

Qualifying Participant Bonus

Some Part B providers can achieve the status of Qualifying Participant (QP) 3 and earn a 5 percent bonus (instead of the MIPS adjustment) on their Part B payments. By significant participation in Advanced Alternative Payment Models (Advanced APMs), providers achieve QP status.

Advanced APMs

MACRA sets requirements for certification as an Advanced APM.4 Advanced APMs are distinguished by extensive use of accredited EHRs quality standards-related payments, and recognition of more than negligible financial risk.



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