Understanding MACRA

Medicare Access and CHIP Reauthorization Act of 2015

MACRA is a U.S. healthcare legislation that gives a framework for reimbursing clinicians who successfully demonstrate quality over quantity in patient care.

MACRA made three important changes as to how Medicare pays providers.

  • Repealed the Sustainable Growth Rate formula that determined Medicare payments for providers' services.
  • Participating providers are now paid based on the quality and effectiveness of care given.
  • MACRA combined existing quality reporting programs into one new system.

The Quality Payment Program

These changes included the creation of the Quality Payment Program (QPP), which helps the healthcare system move toward the goal of value-based care.

The QPP has two paths.

  1. Merit-based Incentive Payment System (MIPS): A program that measures eligible professionals on quality, resource use, clinical practice improvement and meaningful use of certified EHR technology.
  2. Alternative Payment Models (APMs): APMs create new ways for healthcare providers to get paid for the care they provide to Medicare beneficiaries. Some examples of APMs include accountable care organizations, patient-centered medical homes and bundled payment models.
  3. Physicians will select from 300 clinical measures embedded in the MACRA rules, 80% of which are already in the Patient Quality Reporting System.
  4. Providers should optimize their data and use metrics that measure medical outcomes.
  1. Value-based care models are significantly data driven. So providers must not only continually measure, but also continually analyze patient health data, not just collect it
  2. Care coordination is essential to all types of quality measurements and alternative payment models under MACRA regulations. Providers will need to coordinate with each other since patients with chronic conditions move from hospital to skilled nursing to long-term care to home health. Interoperability will be critical so providers can know how to share bundled payments.
  3. Value-based reimbursement -- earning incentives and avoiding penalties -- is based on performance.
  1. The Centers for Medicare and Medicaid Services can award extra bonuses to high-performing doctors and impose further penalties on low-performing ones.
  1. Quality measurement, including such metrics as hospital readmissions and use of outpatient care settings, will start in January 2017 under MACRA rules.
  1. Medicare payments based on quality measures will start being adjusted in January 2019.
  2. There's a "take a break year" from quality measurement in 2018.
  1. Population health is important because alternative payment models will use data and quality scores about populations of patients, not individual patients.

The MACRA final rule relaxes some health data collection and reporting requirements for physicians in 2017, while new health IT certification rules focus on government oversight of EHR vendors on patient safety problems.

The Department of Health and Human Services' release of the MACRA final rule on Oct. 14 came more than a year after Congress overwhelmingly passed the new healthcare law and after much concern in the medical community about its potentially burdensome requirements.

The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, establishes a Quality Payment Program that moves Medicare reimbursement from fee for service to rewards for better medical outcomes.

If they decide not to participate in MACRA's Merit-based Incentive System (MIPS) track, physicians can choose the track of "advanced alternative payment models," such as accountable care organizations (ACOs) and patient-centered medical homes, under which doctors take on financial risk, but also can bear financial rewards.

"Today's rule really marks a shift from when government regulations stopped being the defining element of technology roadmaps and customer needs began to take over," Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services, said during a media conference call.

MACRA will also replace meaningful use for physicians, though the MACRA final rule incorporates some meaningful-use measures, such as "advancing care information." Hospitals are still under the meaningful-use program.