For more than a year, preparations for Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has been like a recently named Cat 5 hurricane brewing off the edge of a fragile coastline. Some provider groups have started boarding up their windows and putting sandbags out while others shrug it off, banking on the winds slowing down or the storm taking a turn before it makes landfall.

Like with hurricanes, fear, apathy, and an air of inevitability seep into discussions of MACRA, legislation that was first signed into law by President Obama in April of 2015.  The legislation is responsible for “changing the healthcare financing system in the most significant and far reaching way since the Program's inception in 1965,” according to the provider group advocacy organization, American Medical Group Association (AMGA).

Whereas most Medicare payments have traditionally been made in a fee-for-service system, MACRA moves the needle on the value-based, or fee-for-value continuum that CMS and other payers are pushing providers toward. Under MACRA, providers will have two payment systems to consider with bonus payments for 2017 care being calculated and distributed in 2019: the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM).

Providers who are in an APM like an ACO are already moving along the value-based continuum and, therefore, do not need to worry about MIPS. The four types of providers identified as APMs for 2017 are:

·         Comprehensive ESRD Care Model (LDO and non-LDO two-sided risk arrangements)
·         Comprehensive Primary Care Plus Model
·         Medicare Shared Savings Program Tracks 2 and 3
·         Next Generation ACO Model

As for everyone else, their laundry list is not that different than those that are in APMs, but they are on a slower, possibly more complex route to risk. They will need to collect a lot of data, and rework their clinical and technological strategies to keep up with MIPS's evolving quality goals and recordkeeping and data sharing requirements. 

Final Rule: 2017 is a Phase-In Year

However, those providers that haven’t made data infrastructure and team-based care investments thus far are in luck for 2017 data reporting, which will affect their 2019 Medicare revenue. First, nearly one third of Medicare clinicians do not meet the Medicare B income threshold to be accountable to MIPS-based payments. Additionally, with the help of AMGA's political influence, physicians were granted a pacing mechanism so they can ease their way into the new, quality and outcomes-based payment methodologies headed their way on the path from fee-for-service.  Therefore weathering the storm in 2017 should be doable for most if not all providers. 

Providers will receive a composite score for each of the following four categories in 2017, with wiggle room to cross-pollinate certain categories:

• Six quality measures (60%)
• Resource Use (0% in 2017, growing to 30% in 2021)
• Five EHR-related measures (some of which can double as clinical practice improvement measures in 2017 only) (25%)
• Clinical practice improvement (15%)

As for the phase-in options for 2017, here is the gist: providers not in an APM can choose between the following three options:

1) Report more than one quality measure, more than one improvement activity, or more than the required measures in the EHR category for more than 90 days but less than a year;

2) Report on all measures for 90 days;

3) Report on one measure in each MIPS category for the entire year

What Does it All Mean?

For Medicare and commercial providers alike, this is the canary in the fee-for-service coalmine. As providers are forced to take on more risk, what does it mean for pharmaceuticals and value based contracting? With MACRA pushing providers forward on the road to value, the inertia could roll other stakeholders along the road, including heretofore reluctant pharmaceutical manufacturers. Cigna, Harvard Pilgrim Health Care, and PBM Express Scripts have already started paving the way for manufacturers on this road.  Who is next, and who is ready for that push on the manufacturer side?

So how will this new mandatory emphasis on data and on outcomes impact provider group strategies? Will they refer out to pharmacists more carefully to ensure they have strong MTM and adherence programs? Could they seek help developing programs of their own?

MACRA may be provider-focused, but any weatherman can see providers are not the only ones that might be in the market for some storm gear.

Learn more at:

https://blog.cms.gov/2016/09/08/qualitypaymentprogram-pickyourpace/

http://blog.ncqa.org/ncqa-responds-cms-new-plan-macra-quality-reporting/

http://healthaffairs.org/blog/2016/08/30/the-roadmap-to-physician-payment-reform-what-it-will-take-for-all-clinicians-to-succeed-under-macra/

http://healthaffairs.org/blog/2016/04/29/breaking-down-the-macra-proposed-rule/

http://www.politico.com/tipsheets/politico-pulse/2016/09/how-cms-will-let-doctors-pick-pace-of-macra-participation-216240