Repeal of the Sustainable Growth Rate (SGR) formula and passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 are proof that what might seem both impossible and improbable can happen.

However, let’s face it, even those closest to the process and those in positions of leadership in the medical community know very little about what is to come with the actual launch of MACRA. We have never been here before. The rules are still being written. Implementation and interpretation vary from practice to practice, hospital to hospital, and system to system. Yogi Berra’s prediction about predictions will hold true: “It’s tough to make predictions, especially about the future.”

What do we know?

• MACRA, or at least the concept of tying reimbursement to outcomes (or measures), is here to stay. Though being rolled out initially through the Centers for Medicare and Medicaid Services, this concept will be agnostic to the type of payer (public, private, single, commercial, voucher system, etc.). There is no going back.
• MACRA is, first and foremost, about controlling total cost. Like SGR, it is designed to slow, reverse, and then limit the growth of total expenditures through Medicare, Medicaid and the Children’s Health Insurance Program, which accounts for the majority of health care spending in the U.S (and about two-thirds of cardiovascular care). If one totals the amount of deferred spending cuts amassed from the beginning of SGR in 1997 and compares it to the minimal “adjustments” called for in MACRA, combined with anticipated inflation, it is a wash. Total public spending on health care will decline about 20 percent over the next 10 years relative to inflation and commensurate with the anticipated growth in number of recipients, based on current eligibility (which itself is likely to change).
• MACRA, in reality, is not about “volume to value.” The winners in MACRA will be those providers, institutions and systems that provide care, no matter what arrangement, to the largest number of people. Bigger accountable care organizations will generate more revenue than smaller ones. Orthopedists doing more total joints in bundles will make more money than those doing fewer.

"Yogi Berra’s prediction about predictions will hold true: "It’s tough to make predictions, especially about the future."

• MACRA is really a system to define “sliding scale” reimbursement and redistribution of available funds to cover care based on achieving pre-specified metrics that may or may not reflect true clinical quality. These metrics are certainly intended to represent “value” and to be surrogates for efficiency and enhanced process of care. As we are learning, some of these metrics, such as chronic heart failure 30-day readmissions, may have a paradoxical, negative impact on actual quality of care.
• MACRA will determine economic winners and losers along a continuum. There is not a “threshold” for receiving better reimbursement. The pie is baked; the slices will all add up to one full pie, not more.
• MACRA will change the economic calculus of health care finances at the provider, hospital and system level. Somewhat counterintuitively, not all winners will be providing the best care and not all losers will be delivering sub-standard care. For example, a system that “over-invests” in staff, technology and other infrastructure to achieve 100 percent of all measures for all providers, without careful planning and detailed financial information, may actually lose money when compared with another system that invests more strategically and may actually reach fewer targets. This “paradox” might be illustrated by two similar systems: Both may deliver the same actual quality of care, but one may have documented it more thoroughly than the other, or one may have focused on what they believe to be more important components (e.g., mortality), rather than other metrics (e.g., 30-day readmissions), or one may have over-spent to build their MACRA process. Beware of unintended consequences. There are other examples of this concept of over-preparation and under-performance. When one looks at return on investment for Meaningful Use and for Value-Based Payment (VBP), there are many examples of practices and systems being financially upside-down. However, the goal of global electronic health record (EHR) adoption and VBP are still the right things to do and likely will have longer term benefits. Nonetheless, perfection may be the enemy of good. All parties will be looking for the Goldilocks “just right” balance between the costs associated with complying vs. the rewards of doing so.
• MACRA is not a cardiology-specific initiative. No doubt, cardiovascular medicine is an important component, as reflected in the proposed metrics and in the portion of all patients receiving cardiovascular care, but it is by no means the main driver. MACRA is still predominantly a primary care-centric incentive plan. Health systems, practices and hospitals that put all their chips on cardiology services alone, at the expense of developing efficient, accessible, high-quality integrated primary care networks, will not be successful. However, the house of cardiology, and especially the ACC, is probably best prepared for this paradigm shift, because of the long-standing commitment to quality metrics, science, evidence based medicine, registries and clinical practice guidelines.
• MACRA will be the vehicle through which the majority of us will receive our care as we age over the next decade, given the average age of cardiologists is 56.
• MACRA will evolve and be tweaked, but its core essence will be retained. We must be nimble enough to change with it and to be engaged enough to influence that change (on behalf of patients, not necessarily ourselves).

How do we prepare for the unknowable, to be successful in MACRA?

• Take great care of patients! Use clinical practice guidelines, appropriate use criteria and evidence-based tests and treatments. This is what we do best and where we as clinicians can have the greatest impact. For some, there is an immediate urge to throw up our hands and wilt at the intimidating complexities of MACRA; however, this is one thing we can immediately and instinctually do to succeed in the new MACRA world order.
• Document, document, document! Encourage health information technology (IT) vendors to build and configure EHRs to do much of this for us faster, better and cheaper!
• Participate in (all) registries.
• Focus on true process improvement: Measure, benchmark, get to the root cause, implement change, re-measure. Rinse and repeat. Focus on real descriptors of quality of care and end points that are meaningful to patients, not just “scorecard” checkboxes.

"MACRA will evolve and be tweaked, but its core essence will be retained. We must be nimble enough to change with it and to be engaged enough to influence that change (on behalf of patients, not necessarily ourselves)." — Richard A. Chazal, MD, FACC

• Innovate and be adaptable. Fellows in Training and early career professionals are already showing us how to do this. Follow their lead. Challenge IT to provide useful tools to be successful.
• Go to meetings like ACC’s Cardiovascular Care Summit, Annual Scientific Session, Legislative Conference, etc. Read extensively outside the traditional clinical literature (read the clinical literature as well). Make what is going on in health care reform a part of the day-to-day conversation at your institution. Become a student of MACRA.
• Embrace and develop multidisciplinary, integrated teams of care and service lines for all specialties. Learn from each other within cardiology and learn from other specialties. Orthopedists have much to teach us about delivering high-quality care within bundled payments.
• Do not be afraid to make mistakes, but recognize failure quickly and learn from those mistakes.
• Remove barriers to access. See more patients. Leverage the whole cardiovascular team to do this.
• Make all operational and strategic decisions patient-centric.

We will see what 2017 brings with respect to MACRA! The good news is that the Cubs won their first World Series in 108 years in 2016 – another seemingly impossible and improbable event. I like to think there is a little bit of each Cubs’ fan eternal optimism in all of us. In 2016, these fans showed us that optimism is not always misplaced.

Edward T. A. Fry, MD, FACC is chair of the Cardiology Division at St. Vincent Health in Indianapolis, IN; chair of the Cardiovascular Service Lines for St. Vincent Health and Ascension Health; and the immediate-past ACC governor of Indiana.

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