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What is MACRA?

MACRA is an acronym for the Medicare Access and CHIP Reauthorization Act of 2015. This legislation, which received bipartisan support from the U.S. Congress, is intended to ensure that physicians are paid fairly, that Medicare Part B costs are controlled and that healthcare is improved.

The passage of MACRA in August 2015 signaled a move away from the Sustainable Growth Rate (SGR) Formula once used to determine physician reimbursement and toward a model based on the quality, efficiency, value and effectiveness of the medical care provided. Under SGR, the annual congressional review process known as the “doc fix” engendered yearly uncertainty about Medicare Part B reimbursements for physicians.

MACRA provides physicians two paths for reimbursements: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM).

MIPS grades health-care providers based on four areas:

These four areas will be reported and benchmarked beginning in 2017 and running through 2018. Under MACRA, physicians will begin to receive reimbursements based on the measured benchmarks in 2019. These reimbursements will be adjusted by increasing percentages through 2022, at which point reimbursements are expected to stabilize.

APM and Advanced Alternative Payment Models will be made available to select physicians with favorable ratings who qualify through participation in Accountable Care Organizations, Patient Centered Medical Homes and Bundled Payment Models.

The bottom line for MACRA is that physicians will be paid based on patient outcomes. However, as every healthcare provider knows, outcomes are not dependent on any one person or clinic. Clear communication and effective data sharing is paramount among the many stakeholders – and that means there is a real need to streamline and simplify the storage and delivery of electronic health records across multiple systems.

A recent survey of 170 medical practices conducted by clinical and business management software company Kareo found that while 85% intended to participate in MACRA, 41% expressed confusion about what the practice required.

The shift to a new evaluation and payment model has had its share of detractors. The Kareo survey found that 60 percent of practices believe that reporting requirements would increase under MACRA, and 63% were not certain if reimbursements would be reduced under MACRA.

Critics also have voiced other concerns about the merit-based formula used to derive MACRA’s value-based payment schedule. One such critic, Texas ophthalmologist Kristen S. Held, spelled out her concerns in an essay in the Journal of American Physicians and Surgeons in the fall of 2016.

Held expressed specific criticisms of the MACRA rules developed by the Centers for Medicaid and Medicare Services (CMS), writing:

“The CMS MACRA rule epitomizes brazen overreach by an Executive Branch agency, including expansion of powers, changing the intent of the law, and violation of Constitutional rights of the people.”

Held, a self-described political conservative and vocal opponent of the Affordable Care Act (Obamacare) who opted out of Medicare, went on to share her opinion that medical care in the United States has been “criminally politicized.”

“Despite the fact that physicians spend their lives training and serving their patients to the very best of their abilities, it is assumed that they need a government scheme for communicating expectations and evaluating performance,” Held wrote.

As mentioned above, however, the legislation received bipartisan support in congress, including “yes” votes from two conservative lawmakers: Speaker of the House Paul Ryan, R-Wis., and Rep. Tom Price, R-Ga. Price is President Donald J. Trump’s nominee for Secretary of Health and Human Services.

MACRA was meant to replace an increasingly anachronistic payment system with a system based on how well physicians do their jobs. As healthcare consultant Katherine Watts of Horne LLP wrote for Quality Digest, “The old system wasn’t working and devising a way to reimburse physicians fairly, control costs, and improve the quality of care benefits all stakeholders.”

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