Here Are the MACRA Questions Every Healthcare Provider Must Ask

MACRA is the next generation of healthcare legislation, and it's sweeping. The new rule hopes to drive the mass transition to value-based reimbursement, with doctors getting paid based on the quality of their work and the steps they take to improve their practices.

The successor to the Sustainable Growth Rate rule, MACRA replaces the cuts with a 0.5 percent guaranteed increase in payments, followed a few years later by a freeze in payments. The law also takes the existing physician quality reporting system (pay-for-reporting), meaningful use of electronic health records, and the value-based payment modifier (pay-for-performance) and rolls them into one giant program called the Merit Based Incentive Payment System. MIPS has one scoring system and one set of dollars at risk.

"At first, it does actually lower the dollars at risk and then grows it back up," said Danielle Lloyd, Deputy Director of Premier Washington D.C. office and their VP for Policy and Advocacy. Premier Inc. helps healthcare entities improve performance. "Part of that is in recognition that in creating this program, it is going to take some time to understand it."

With MIPS, eligible clinicians will be measured and paid based on four primary metrics: quality, resource use, clinical practice improvement activities and meaningful use of EHR systems. Under a second path, if you also participate in alternative payment models at the same time, you get special preferential scoring under MIPS. Some of these APMs, like accountable care organizations, carry no direct risk and can provide a boost in MIPS performance, but this track has a time limit of six years before you either have to move up to risk or move down to MIPS alone, depending on how you fared, Lloyd said.

Advanced APMs represent a third path, and providers can get 5 percent bonuses on professional services and get out of MIPS if they participate. This most advanced path involves even higher levels of reimbursement but assumes the highest risk.

"The idea is to try to use a carrot to get organizations to move over to the more advanced payment models," Lloyd said. "The intent of the MACRA bill is absolutely consistent with the administration's goal of having 50 percent of traditional Medicare fee for service in APMs by 2018, but the Advanced APMs for which you get a bonus under MACRA is only a subset of the administration's definition." Depending on the final rule, CMS is shooting for only 10 to 15 percent of eligible clinicians getting the 5 bonus at first.

Lloyd said it's best to figure out your strategy now, as payments in 2019 are based on performance in 2017. Barring a delay that was hinted at as a possible option by CMS Acting Administrator Andy Slavitt at a July 13 Senate Finance Committee hearing, implementation could be just a few short months away. Lloyd said there are going to be questions you have to ask yourself to decide which strategy to take.