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Tuesday, May 3, 2016

Paying for Value: First Glance at the New MACRA Rule

Last Wednesday, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to implement key provisions of the Medicare Access & CHIP Reauthorization Act. Passed with bipartisan support in 2015, MACRA, as it is called, represents the biggest change to how Medicare pays for care in decades. This law is also an important opportunity to improve the quality of care delivered through Medicare. Given the number of people who are enrolled in Medicare and the number of providers who see Medicare patients, these changes will have a significant impact throughout the entire health care system.

CMS has already implemented different models and demonstration projects that tie payment for health care services to the quality of those services.

MACRA will accelerate this movement to value-based payments via two pathways:

1. Alternative Payment Models: Providers are given incentives through larger fee increases and bonus payments to join alternative payment models, such as accountable care organizations or patient-centered medical homes. Though there are different kinds of models, these alternative payment models generally seek to improve the quality of care and reduce costs through improved care coordination and through agreements among providers to share financial risk for the total cost of a person’s care.

In analyzing the proposed rule, we will be looking to ensure that the requirements for these models include consumer protections, such as provider choice and transparency regarding provider financial incentives. Alternative payment models should also focus on providing patient- and family-centered care, making a commitment to shared decision-making, and eliminating disparities in access to care and in health outcomes. 

2. Merit-Based Incentive Payment System: Providers who are not part of an alternative payment model that meets MACRA’s requirements must participate in the Merit-Based Incentive Payment System (MIPS). Each provider (or group of providers) will be evaluated across four categories, and how well providers do in these categories determines whether they receive a bonus payment adjustment or a penalty payment adjustment. These categories are:

  • Quality: Providers must choose certain quality measures to report.
  • Resource Use: Uses Medicare claims data to measure total and condition or episode-specific costs of providing care.
  • Advancing Care Information: Measures the use of electronic health records and other health IT practices.
  • Clinical Practice Improvement Activities: Includes a range of activities across many different subcategories designed to improve access, care coordination, and patient and family engagement.

In analyzing the proposed rule, we want to ensure that the requirements for quality include measures that are meaningful to patients and include outcomes measures, especially patient-reported outcomes. The activities under the clinical practice improvement category have the potential to really drive improvements in how care is delivered and how families and patients are engaged. Under this category, we’ll be looking for requirements that engage patients and families not only at the point of care, but also in the governance structures of health care provider practices, and requirements for engaging with community and social services.

Over the next few weeks, we’ll look at the rule in greater detail.

We will be submitting official comments to CMS, which are due on June 27. Stay tuned.