5 Things to Know About the New MACRA Rule

This sweeping proposal is the biggest step yet in shifting reimbursement from a volume-based to a value-based system. Stakeholders offered mixed opinions this week.

On Wednesday, CMS released a 962-page proposal to implement the 2015 law, the Medicare Access and CHIP Reauthorization Act, or MACRA. This sweeping overhaul of how Medicare pays doctors is the boldest step yet toward shifting reimbursement from a volume-based to a value-based system. Here are 5 things to know about the proposed regulations:

1. Several existing programs would be streamlined. A host of separate programs affecting doctors—the Physician Quality Reporting System, the Value-Based Payment Modifier, and the Medicare EHR Incentive Program—will be combined into a single scoring metric called MIPS, for Merit-Based Incentive Payment System. Reimbursement will be based on 4 areas: quality, cost, technology use, and practice improvement. CMS expects most doctors to use this system, but others may be eligible for the more flexible Alternative Payment Models (APMs).

2. “Meaningful Use,” which many loathe, will go away. A new system, Advancing Care Information, would replace the current EHR reporting requirements starting January 1, 2017. This was a priority of the American Medical Association (AMA), and its president, Steven J. Stack, MD, praised CMS for hearing its concerns. The rule trims the number of measures from 18 to 11, gives physicians and other eligible professionals 50% credit just for reporting on measures, and lets physicians design the other 50% around metrics tailored to their practices. (Because MACRA does not involve Medicaid, no changes to meaningful use are proposed here, but CMS officials say they will address this.)

3. Limits on “Alternative Payment Models” have drawn fire. Unlike the AMA, the American Hospital Association reacted harshly to CMS’ definitions on what it takes to qualify for the APM system, which allows more innovative risk models and greater ability to invest in care coordinators. AHA blasted CMS for leaving out bundled payments and Track 1 of the Medicare Shared Savings Program, just as doctors are gaining comfort with them. CMS’ standards for APM include meeting benchmarks for certified EHR use over a 2-year period. This will be a major area of contention between now and the final adoption of the rule.

4. Some fear that once again, small players will be pushed aside. Critics say the regulations favor hospitals and large systems at the expense of independent practices, and that will mean more consolidation. Even Farzad Mostashari, MD, ScM, who called the proposal the most “substantive change to how healthcare is paid for in a couple of decades,” said it had a “blind spot” in its assumptions about primary care providers and accountable care organizations, which would need to be fixed.

5. Remember the saying, “It ain’t over till it’s over.” With so much on the line, stakeholders who aren’t happy with the proposal will press furiously for changes, both ahead of the June 26, 2016, comment deadline and into the fall, when the MACRA rule will be adopted. Both AMA’s Stack and CMS referred to the proposal as a “first step” on what promises to be a very interesting road.

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