On April 19, the House Energy and Commerce Subcommittee on Health held a hearing to examine the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 and efforts of clinicians to prepare for the new Medicare payment system.

While the legislation repealed the flawed Sustainable Growth Rate formula and paved the way for a new payment system, there is a significant amount of uncertainty for the health care community. The congressional hearing provided an opportunity for clinicians to share insight into MACRA challenges, how the law will impact health care providers and what is being done to prepare for a successful implementation. The Subcommittee held another hearing in March that focused on the Centers for Medicare and Medicaid Services' (CMS) efforts surrounding MACRA.

"Since the passage of MACRA, the ACC has been engaged in conversations with the cardiovascular community as well as CMS about the intricacies of implementing this law – and those conversations have been positive and productive," said ACC President Richard A. Chazal, MD, FACC, in a statement. "As MACRA is implemented, the College encourages CMS to note that quality and value are not one-size-fits all concepts. Therefore, the new payment system must be streamlined and flexible to ensure that the system truly rewards clinicians across all specialties for their efforts to provide evidence-based care and seek innovative ways to manage costs without threatening patient outcomes."

The importance of putting electronic health records (EHRs) at the center of the new system was stressed throughout the hearing. Several clinicians emphasized that meaningful data and EHR interoperability are key to improving care and must be core components of MACRA. It was also made clear that specialists and primary care providers must work together to treat populations of patients instead of practicing in silos. Additionally, while the Center for Medicare and Medicaid Innovation (CMMI) laid the groundwork for health care innovation, the hearing highlighted the potential of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), created by MACRA and driven by physicians, to impact the future of the Medicare payment system.

Ahead of the hearing, the ACC submitted a statement for the record [PDF] highlighting its efforts to educate the entire cardiovascular care team on the transition from the current value-based payment programs to new initiatives under MACRA. The College has developed a MACRA Taskforce, held webinars, published articles in the Journal of the American College of Cardiology, hosted sessions at ACC.16 with representatives from CMS and created a hub on ACC.org with the latest MACRA information and resources.

In its statement submitted to the Subcommittee, the ACC also underscored the following MACRA recommendations that were made to CMS in fall of 2015 as part of the agency's request for information:

• The Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) pathways should be based first and foremost on supporting the clinician's ability to provide high-quality, evidence-based care to Medicare beneficiaries.
• The new payment system under MACRA must apply appropriate measures and requirements that recognize the diversity of clinicians and patient populations, and CMS must continue to work with medical specialty societies and practices to ensure that program requirements fit within the clinician workflow and are not administratively burdensome.
• Since Meaningful Use (MU) is a component of the MIPS score, CMS should reopen MU Stage 3 to realign the program to focus on interoperability and usability, and evaluate whether clinicians are successful under the Stage 2 Modifications rule. CMS must also eliminate the pass/fail approach to the program before integrating it into the MIPS program.
• Quality measure reporting requirements should be based on clinicians reporting the most clinically meaningful measures based on their specialty and services provided. Arbitrary thresholds such as reporting a certain number of measures according to the National Quality Strategy should be eliminated.
• The collection of valid performance data is essential to a pay-for-performance system. CMS should collaborate with Qualified Clinical Data Registry vendors such as the ACC and practices so all stakeholders can better understand any data issues and work together to resolve them if they arise.
• All resource use measures should be appropriately risk-adjusted so clinicians are not penalized for treating chronically ill patients. In addition, each resource use measure must be counter-balanced with an appropriate quality measure.
• CMS should not mandate participation in any specific activity under the new Clinical Practice Improvement component of the MIPS program. Clinicians should be permitted to participate in those activities that meaningfully drive improvements in care based on their patient population, specialty and practice size.
• CMS must provide clinicians with usable, accessible and actionable feedback reports that truly allow them to assess their performance and identify areas for improvement. Current feedback reports provided by CMS, such as the Quality Resource and Use Report, are highly technical and difficult for many clinicians to understand.
• CMS and CMMI should continue to work with the private payer and clinician communities to align quality measures and reporting requirements, allowing clinicians to easily transition between the MIPS program and APM participation.

The College's comments also addressed the need for the MACRA process to recognize the "unique role specialty providers play" in the health care system. "Cardiologists typically care for patients who have multiple complex conditions and require coordination between multiple clinicians. New payment models should be reflective of this population and the clinicians who care for them."

The ACC will continue to work with the CMS throughout the regulatory process to establish details of how the law will function. Stay tuned to ACC.org/MACRA for the latest information and resources.

Keywords: Advisory Committees, Centers for Medicare and Medicaid Services, U.S., Chronic Disease, Electronic Health Records, Mandatory Reporting, Meaningful Use, Medicaid, Medicare, Physicians, Primary Health Care, Registries, Reimbursement, Incentive, Societies, Medical, Specialization, Medicare Access and CHIP Reauthorization Act of 2015

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