Overview of the Medicare Access and
CHIP Reauthorization Act (MACRA)
Stephanie Glover
Health Policy Analyst
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About us
The National Partnership for Women & Families is a nonprofit,
nonpartisan advocacy group dedicated to promoting fairness in the
workplace, access to quality health care, and policies that help
women and men meet the dual demands
of work and family.
More information is available at
www.NationalPartnership.org.
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Housekeeping Items…
 All lines are open, please mute your phone
 If there is background noise we will have to mute everyone but you’ll be able
to unmute yourself by pressing *6. We’ll let you know if that’s necessary!
 Feel free to ask questions or make comments along the way
 The webinar should last about an hour with time for
discussion at the end
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Agenda
 Context and history of the SGR
 Summary of MACRA provisions related to Medicare physician
reimbursement
 Deeper dives into MIPS and APMs
 Impact points for consumers and opportunities for comment
 Next steps
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Context: History of the SGR
 Previous payment system (SGR) implemented in 1997
 Patched 17 times (@ $150 B in “fixes”)
 Unsuccessful efforts to repeal/replace it over the last decade
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Context: History of the SGR
 What was different this year?
 Growing consensus of need to shift away from fee-for-service
 Strong and uniquely unified push by physician community
 Bipartisan, bicameral consensus on the policy with highly committed
Congressional leadership
 Result: Overwhelming support
 92 – 8 Senators; 392 – 37 Representatives
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What does MACRA do?
 Eliminates annual uncertainty (payment cliff) by stabilizing
payment updates
 Combines three physician-level incentive programs into one
 Extends key programs including CHIP, community health
centers, and the performance measurement enterprise
 Big takeaway: Meaningful progress toward paying physicians
for value, not volume
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What does MACRA do?
 Repeals the SGR
 Establishes a merit-based incentive program (MIPS)
 Incentivizes the development of, and participation, in
alternative payment models (APMs)
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What does MACRA do?
 Immediately replaces old SGR cycle with shortterm stable updates, then offers two paths
Jan-June
2015
0.0%
July-Dec
2015
0.5%
2016-2019
0.5%
2020-2025
0.0%
2026+
0.25% MIPS
0.75% APMs
Status quo: PQRS, Physician Value
Modifier, MU Bonuses/Penalties
through 2018
MIPS Bonuses/Penalties
APM
Bonuses
2019-2024
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Unpacking the Merit Based Incentive
System (MIPS)
Four components contribute to a MIPS score from 1- 100:
 A physician participating in a practice certified as a patientcentered medical home will receive the highest potential score
for clinical practice improvement activities
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MIPS: Rewards and Penalties
 Providers earn a 1-100 score based on performance from four
MIPS categories
 Payment updates based on this score would be adjusted (up
or down) by:
 4 percent in 2019
 5 percent in 2020
 7 percent in 2012
 9 percent in 2022
 Additional payment above performance threshold; capped at
$500 million/year (2019-2023)
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MIPS: Measure Criteria
 Measures from existing programs; new and updated
measures must be evidence based and come through
traditional rulemaking processes
 If new measures are not endorsed by a consensus-based
entity (now NQF), CMS must first submit to a peer review
journal
 Multistakeholder input is required, but emphasizes medical
specialty societies over existing process (MAP)
 How this statute is operationalized in regulations will be key
to meeting ultimate goals
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Incentives to Participate in APMs
Jan-June
2015
0.0%
July-Dec
2015
0.5%
2016-2019
0.5%
2020-2025
0%
2026+
0.25% MIPS
0.75% APMs
Status quo: PQRS, Physician Value
Modifier, MU Bonuses/Penalties
through 2018
MIPS Bonuses/Penalties
APM Bonuses
2019-2024
(5%)
Special emphasis on testing APMs with specialists & small
practices
Potential for development of new APMs by 2019
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Unpacking the Alternative Payment
Models (APMs)
Three criteria:
1.
Qualifying Model
2.
Quality Measures
3.
Financial Risk
Note: certain CMMI approved patient-centered medical homes
would be exempt from financial risk
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Three Impact Points for Consumers
 Developing criteria for Patient Centered Medical Homes
 Developing cross-cutting criteria for Alternative Payment
Models
 Setting priorities for the MIPS quality measure set
 Other areas?
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Opportunities for Input
JulAug
SeptDec
2015
JanMar
AprJun
JulAug
OctDec
2016
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Patient Centered Medical Homes
 Big incentive for providers to participate in patient centered
medical homes – but what does that mean?
 What we think: A truly patient-centered medical home is
grounded in comprehensive and well-coordinated primary
care.
 Exemplar patient-centered medical homes utilize care teams that partner with
the patient and family caregivers, provide ready access to care, address
patients’ unique needs and preferences, view patients and family caregivers as
partners in care planning and treatment decision-making, and provide safe,
timely, and effective care.
 Need for consumers to weigh in and fill in the details for
CMS.
Alternative Payment Models
 Again, major incentive for providers to engage in alternative
payment models but no clear definition in the statute other
than a few criteria
 What we think: If designed and implemented correctly,
alternative payment models have the potential to provide the
comprehensive, coordinated, patient- and family-centered
care patients want and need while helping to drive down
costs.
 Only through meaningful partnership with consumers and family caregivers
will we arrive at a transformed health care system that delivers on all three
tenets of the Triple Aim – better care, better experience, and lower cost.
 Need for consumers to weigh in and fill in the details for
CMS.
Priority Measure Gaps
 What measures are needed to evaluate MIPS and APMs?
What are the current gaps?
 Measures that are important to patients: PROMs, care coordination, patient
experience, patient-centeredness
 Cross-cutting measures, e.g., patient experience, patient-reported health status
 Patient experience measures: need information more quickly and shorter
surveys
 Measures of appropriate use
 Patient-reported measures, including functional health status and quality of life
 Measures to identify and address disparities
 Measures for efficient use / total cost of care
 Outcome measures
 Composite quality measures: highly prevalent conditions, preventive care,
surgery
 Other?
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Next Steps!
 What are we missing?
 Are there other areas for input that you’ve identified?
 Scheduling calls to discuss each of these impact points in more
detail
 Submit recommendations to CMS
 Questions?
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For more information
Contact us:
Lauren Birchfield Kennedy
Director of Health Policy
[email protected]
Stephanie Glover
Health Policy Analyst
[email protected]
Follow us:
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www.twitter.com/npwf
Find us:
www.NationalPartnership.org
www.CampaignforBetterCare.org | www.PaidSickDays.org
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