Medicare

MACRA, 2 years later: 9 ways to make it better

Two years in, the Medicare Access and CHIP Reauthorization Act (MACRA) remains a work in progress, but there are several specific steps Congress can take with MACRA and its Quality Payment Program (QPP) that will help physicians succeed and patients thrive.

“The QPP is a complex program that remains challenging for CMS to implement and difficult for physicians to understand,” AMA President Barbara McAneny, MD, told the U.S. Senate Finance Committee at a May 8 hearing. “However, the AMA is confident that if Congress, the Centers for Medicare & Medicaid Services, and the medical community continue to work together to improve the program, we can ensure physicians have the opportunity to be successful and provide high value care to patients.”

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To improve MACRA programs, Dr. McAneny prescribed three priorities and six suggested technical adjustments.

Continue support for small and rural practices. The AMA appreciates and supports accommodations Congress has made for low-volume practices in the QPP’s Merit-based Incentive Payment System (MIPS), but small and rural practices are still struggling. Dr. McAneny told the panel about how her private oncology practice in New Mexico recently had to close three of its rural cancer clinics.

She noted that small and rural practices finished well below the national averages on MIPS scoring and urged Congress and CMS to continue to implement policies that will help these practices succeed in MIPS.

Extend the bonus period for physicians investing in advanced alternative payment models (APMs). MACRA provided for a six-year bonus period for physicians who expend the resources necessary to transform their practices’ operation into an advanced APM. This provided a smooth glide path for transitioning to innovative value-based payment models, but “a dearth” of APM options has limited physicians’ ability to take advantage of this pathway.

With only three years remaining, Dr. McAneny told senators that there is not enough time left for physicians to make the necessary technology investments and workflow-design changes necessary to operate as an APM.

The AMA is encouraged by new models recently released for testing by the Center for Medicare and Medicaid Innovation, and urges that the bonus period be extended another six years “to provide physicians a realistic onramp to participation in value-based care,” Dr. McAneny said.

Replace the scheduled payment freeze with annual updates. Physician payments are set to be frozen from 2020 through 2025. This would occur as physician costs are projected to rise by an average of 2.2% a year.

Replacing the freeze with positive updates would “provide physicians with a stable and sustainable revenue source that allows them a margin to invest in practice improvements in order to transition to more efficient models of care delivery to better serve Medicare patients,” Dr. McAneny said.

In addition to these three priorities, Dr. McAneny and the AMA suggest these technical changes:

  • Update the MIPS Promoting Interoperability performance category to allow physicians to use certified electronic health record technology (CEHRT) in more clinically relevant ways.
  • Develop a separate threshold for small and rural practices to ensure a level playing field for all physicians.
  • Prioritize cost measures that are valid and actionable and have stronger correlation between costs and the physicians’ influence over those costs.
  • Incentivize reporting on new quality measures, especially specialty developed and recommended measures.
  • Eliminate the requirement to set the performance threshold at the mean or median so CMS, rather than a pre-set formula, can determine whether physicians are ready to move to an increased threshold based on available data.
  • Align and improve methodologies of MIPS calculations and Physician Compare. Physicians now receive two different scores and reports, which is confusing to doctors and patients and does not lead to quality improvement.

“We believe the goal of the program should be to help physicians succeed, not to cause physicians to fail, and we believe these technical changes, along with other changes, will allow CMS to increase the program requirements gradually and transition to a more meaningful program over time,” Dr. McAneny said.

She added that, despite all the changes that need to be made, the QPP remains an improvement over the sustainable growth-rate (SGR) payment formula that it replaced.