New Payment Models Ahead: What's on the Horizon for the Medicare Payment Landscape

With the U.S. health care system undergoing a momentous transition from a volume-based fee-for-service model to one focused on value and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) initiating new payment pathways, Medicare reimbursement is a hot topic across the health care spectrum.

During several sessions at ACC.16, experts walked through what’s on the horizon for the Medicare payment landscape and how physicians should prepare for the changes. A session co-chaired by Paul N. Casale, MD, MPH, FACC, and Karen E. Joynt, MD, MPH, zoomed in on what new payment models mean for interventional cardiology. “MACRA repealed the Sustainable Growth Rate and left something more confusing in its place,” noted Joynt. “Now is the time for cardiology to get involved.” During the James T. Dove Lecture, Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, offered a closer look at the transition from volume to value and the role physicians and other health care providers can play going forward. "Physicians must play the lead role in creating a higher-value health care system, because only physicians can redesign the way services are delivered to reduce spending without harming quality or access for patients,” said Miller. Another session titled “Piecing Together the MACRA Puzzle” featured speakers from the Centers for Medicare and Medicaid Services and the American Hospital Association who discussed opportunities under the new payment system and how hospitals are preparing for MACRA.

While MACRA legislation is written with broad directions that will be implemented through more specific regulation by the federal agencies over the next few years, physicians are already beginning to be paid differently than in the past. In March, the U.S. Department of Health and Human Services announced that it had achieved its goal of linking 30 percent of all Medicare payments to quality through alternative payment models (APMs) nearly a year ahead of its original prediction.

APMs, one of the payment pathways under MACRA, are designed to encourage providers to take on financial risk for the health outcomes of an entire patient population. This approach demonstrates accountability not only for individual patients, but for an entire group of people. Furthermore, APMs tie financial risk to quality metrics that enhance information sharing, facilitate transitions of care and ultimately improve care coordination between all entities involved.

MACRA also created the Merit-Based Incentive Payment System (MIPS). Eligible professionals who participate in MIPS will receive annual payment increases or decreases based on their performance. Furthermore, the three existing quality reporting programs – the Physician Quality Reporting System, Meaningful Use and the Value-Based Payment Modifier – are streamlined into one system under MACRA along with a new Clinical Practice Improvement category.

There’s no question that practice quality improvement efforts, quality reporting and value-based reimbursement are here to stay, and will undoubtedly be a critical part of provider payment models regardless of how the details unfold. “The ACC is already at the table working to minimize challenges and take advantage of opportunities under the new system to support policies that facilitate evidence-based, cost-effective and high quality care,” said Immediate Past President Kim Allan Williams Sr., MD, MACC, during ACC.16.

Stay up-to-date on MACRA developments and resources at

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