MACRA - A Brief Review

September 29, 2017 | Charles Beale, MD

Another calendar year has passed, and so has this year’s ACC Legislative Conference in Washington, DC.  The ACC has continued to promote advocacy for our patients and our members. They have been instrumental in preparation for us to remain legislatively responsible and educated with regards to the implementation of Medicare Access and Chip Reauthorization Act (MACRA). As FITs, MACRA will influence how we practice, bill and subsequently document in the future; therefore, we should begin to familiarize ourselves with what is happening. For many FITs, we are poorly equipped to advocate for ourselves due to the bombardment of MACRA acronyms. If you would like to read more about MACRA, there is a “thorough” 2,398-page document you can refer to, but I will attempt to scratch the surface to peak your interest.

MACRA was conceived by the Obama administration in 2015 to replace the pre-existing payment model. The hope was that they could focus on quality, value-based care as opposed to just quantity. In the new model, Quality Payment Program (QPP), we will choose from two payment structures: the Merit based Incentive Payment System (MIPS) or an Advanced Alternative Payment Models (APMS). Most of us will be joining MIPS and this will be the focus of our discussion. To qualify, participants must bill Medicare more than $30,000 in Part B and provide care for more than 100 Medicare patients a year. This year was the first year Medicare began collecting data. The QPP requested reporting at your “pace” for this year, 2017. The MIPS is composed of four areas of submission: quality, advancing care information, improvement activities and cost.

Quality will uphold 60 percent of the evaluation and is the easiest to discuss. Some of the quality measures for cardiology are part of our daily lives and would not require a change in how we practice, but would require attention to how we report it. For example, aspirin use for your patients with ischemic vascular disease will be one of the quality measures. Your system of reporting may neglect to document all patients taking aspirin because a large portion of your patient population buys their aspirin over the counter. Despite ensuring every patient is on aspirin who meets the indication, if it is not appropriately recorded, you may receive a reduced financial payment if your aspirin use rate is less than your peers. Reimbursement benefits based on reporting may be as high as plus or minus 9 percent by 2019. Furthermore, this will be publicly reported and it will be public knowledge that your practice performs below average. Conversely, the MACRA quality based reimbursement scheme may help with smoking cessation. Financial incentives may serve as a great motivator to discuss smoking cessation with your patients. It will likely inspire cardiologists to create novel ways to discuss and promote smoking cessation resulting in great health outcomes. The other quality measures for cardiology are listed here. I recommend taking a moment and familiarizing yourself with them as a first step in preparation for your future.

The next area would be advancing care information. Advancing care information aims to reward practices that utilize electronic medical record with safe transmission of health information between care givers, along with encouraging e-prescribing and rewarding practices that foster electronic access for patients outside of the office or hospital. The third category is named improvement activities. The goal of this category is to ensure patients have access to clinical care. This would reward practices that have 24/7 support with access to the patient’s medical record. It would also reward practices participating in self-assessment and improvement of outcomes and patient satisfaction. This category may serve to inspire individuals or practices to evaluate outcomes and create methods for improvement whom otherwise would never have taken the time to look. The last category has yet to have requirements for reporting this year, and is aimed at creating efficient spending in Medicare by providers. The future of this category is to reward clinicians whom can provide the same quality of care but for a lower cost.

The ACC has ensured that we are continually part of the conversation as MACRA evolves, but it is the responsibility of each physician to be aware of the changes. MACRA is confusing to everyone, but the horizon for young budding physicians has never looked brighter. MACRA itself is a remarkable bipartisan achievement, which has the ultimate goal to transform health care to provide high quality care at a reduced price. This presents a tremendous opportunity for innovators and FITs – to create new methods and ideas to maximize the utilization of limited resources and funding, and to ensure a greater number of sick patients in the future can receive care in this great country.

This article was authored by Charles Beale, MD, a Fellow in Training (FIT) at Brown University in Providence, Rhode Island.