MACRA 101: Back to Basics
Stephanie Glover
Health Policy Analyst
Erin Mackay
Associate Director
Health Information Technology Programs
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.
Key health initiatives:
 Coalition for Better Care: A broad-based coalition of consumer
organizations with a direct stake in improving health care quality for
patients and family caregivers.
 Consumer Partnership for eHealth: Advancing health information
technology in ways that benefit patients and families.
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Agenda
 Context of MACRA
 Summary of MACRA provisions related to Medicare physician
reimbursement
 Deeper dives into MIPS and APMs
 Intersection of MACRA and Meaningful Use
 Impact points for consumers
 Next steps and comment letters
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MACRA: Shifting from volume
to value
 Previous physician payment system, the Sustainable Growth
Rate (SGR), implemented in 1997
 Growing consensus of need to shift away from fee-for-service
 MACRA:
 Eliminates annual uncertainty (payment cliff) by repealing the SGR
and stabilizing payment updates for physicians
 Extends key programs including CHIP, community health centers, and
the performance measurement enterprise
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Where are we now?
 Medicare Access and CHIP Reauthorization Act (MACRA)
passed April 2015
 Request for Information released September 2015
 NPWF submitted comments November 2015
 Notice of Proposed Rulemaking (NPRM) imminent..
 Sent to OMB March 28
 60 day comment period expected
 Final rules expected by November 2016
 Consumer input will be critical!
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Why should consumers care?
 Big takeaway: Meaningful progress toward paying physicians
for value, not volume
 Establishes a merit-based incentive payment system (MIPS)
 Combines three physician-level incentive programs into one:
Physician Quality Reporting System
Value-Based Modifier
Meaningful Use Electronic Health Record (EHR) Incentive Program
 Incentivizes the development of, and participation, in
alternative payment models (APMs)
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Worlds colliding:
MACRA & Meaningful Use
1) Merit-Based Incentive Payment System (MIPS)
 Awards EP single composite performance score based on four
categories:
 Meaningful use of certified EHR technology (one of four categories)
2) Alternative Payment Models (APMs)
 Use certified EHR technology (among other requirements)
 Technology certified by the federal government to include functionality
necessary for fulfilling Meaningful Use requirements
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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
Payment System (MIPS)
Awards providers a single composite performance score based on four
categories:
1. Quality
 Incorporates measures from the Physician Quality Reporting System
2. Resource use
 Incorporates the existing Value-Based Modifier
3. Meaningful use of certified Electronic Health Record (EHR) technology
 Incorporates measures from the EHR (“Meaningful Use”) Incentive Program
4. Clinical practice improvement activities
 NEW category!
 Includes activities regarding expanded practice access, population management, care
coordination, beneficiary engagement, patient safety, etc.
 A physician participating in a practice certified as a patient-centered medical home will
receive the highest potential score for clinical practice improvement activities.
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MIPS scoring
Four components contribute to a MIPS score from 1- 100:
 Changes in weighting:
 Quality is weighted at 50% in 2019, and 45% in 2020
 Resource Use is 10% in 2019, and 15% in 2020
 Meaningful Use can be reduced (but not below 15%) if >75% of providers are Meaningful Users
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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 as much as:
 4 percent in 2019
 5 percent in 2020
 7 percent in 2021
 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
 Multi-stakeholder input is required, but emphasizes medical
specialty societies over existing process
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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
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Unpacking the Alternative Payment
Models (APMs)
Qualifying Model of Alternative Payment Models include:
 Models implemented through the Center for Medicare & Medicaid Innovation
(CMMI)
 Medicare shared savings program
 Health care quality demonstration program
 Demonstration project required by federal law
Three criteria:
1.
Quality Measures Comparable to MIPS
2.
Use of Certified Electronic Health Record (EHR) Technology
3.
Bear “More than Nominal” Financial Risk
Note: certain CMMI approved patient-centered medical homes would be exempt
from financial risk
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Impact points for consumers
Setting priorities for:
 Patient Centered Medical Homes
 Alternative Payment Models
 The “meaningful use” of health IT
 The MIPS quality measure set
 Clinical practice improvement activities
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Patient Centered Medical Homes
 Question: How will CMS define patient-centered medical
homes?
 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.
 Key issue to look for in the proposed regulation
Alternative Payment Models
 Question: How will CMS define Alternative Payment Models?
 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.
 Key issue to look for in the proposed regulation
Meaningful use of health IT
 Question: How will Meaningful Use be integrated into new models
of care under MACRA?
 What we think: Health IT is foundational to patient- and familycentered care.
 At a minimum, include Meaningful Use measures that address patient
and family engagement and care coordination in both MIPS and
APMs:
 Patient ability to view online, download and share health information
 Access and use requirements!
 Secure email messaging between providers & patients
 Incorporate patient-generated health data into EHRs
 Exchange, reconcile, and integrate data between providers
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Meaningful use of health IT
What we think:
 MIPS should retain following structural elements of Meaningful Use
program:
 100% attestation (providers must meet all required measures to
succeed)
 Full-year reporting periods (vs. 90 days)
 APMs should encourage use of functionalities of Certified EHR
technology not yet included in the Meaningful Use program, such as:
 Person-centered health and care plans
 Non-English language access (to educational materials and clinical
information)
 Links to community resources, supports, and services
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Measures that matter
 What measures are needed to evaluate MIPS and APMs?
 Measures that are important to patients: PROMs, care
coordination, patient experience, patient-centeredness
 Outcome measures
 Patient experience measures: need information more quickly and shorter
surveys
 Patient-reported measures, including functional health status and quality of life
 Cross-cutting measures, e.g., patient engagement, care coordination
 Measures to identify and address disparities
 Measures of appropriate use
 Measures for efficient use / total cost of care
 Composite quality measures: highly prevalent conditions, preventive care,
surgery
 Other?
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Next steps
 Coming soon: Notice of Proposed Rulemaking (NPRM)
 Additional webinars to analyze rule, gather reactions and feedback
 Plans for comment:
 National Partnership for Women & Families
 Coalition for Better Care
 Consumer Partnership for eHealth
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Save the date!
Clinical Practice Improvement Activities: What Consumers Want
Thursday, April 28
3:00 pm Eastern
http://npwf.adobeconnect.com/cpias/
 Beneficiary / patient engagement
 Shared care planning
 Decision aids / medical discussion guides
 Other ideas?
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For more information
Contact us:
Stephanie Glover
Health Policy Analyst
[email protected]
Erin Mackay
Associate Director, Health IT Programs
[email protected]
Follow us:
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www.twitter.com/npwf
www.twitter.com/CPeHealth
Find us:
www.NationalPartnership.org
www.CampaignforBetterCare.org |
www.NationalPartnership.org/CPeH
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