Understanding MACRA – State of United States Healthcare
So I’ve been meaning to write about this for a while but I simply felt that I still didn’t know enough about it to be able to actually write something about it. I’ve always been someone against misinformation and since MACRA is a huge concept and new bill that was passed into law early last year, I wanted to make sure at the very least, I had a good cursory understanding of what it is, what it does, and who it effects. Especially since this website is dedicated to my academic pursuits and me learning, I wanted to make sure that I didn’t publish an incorrect perspective and understanding of what MACRA is, and if anyone else stumbled upon this post, I’d hate for them to also have the wrong understanding and thus spreading misinformation. All that aside, let’s dig into the real meat and bones with the Medicare Access and CHIP Reauthorization Act (MACRA), regarding a revamp of Medicare reimbursements.
With MACRA, What Happens to Meaningful Use (MU)
With the Patient Protection and Affordable Care Act (commonly known as the ACA or Obamacare) at a whopping 906 pages, MACRA beat it out with 962 pages in all its glory. Now, only the most involved and healthcare economists have dared to actually read all 906 pages, so I highly doubt that the MACRA bill is actually going to get much reading time by anyone but fortunately there have been many reputable sources that have attempted to cut down on this difficult task and compiling it all together, I wanted to put together some things that I learned. Essentially, MACRA is the new big brother to the Meaningful Use doctrine in healthcare and more importantly in healthcare IT. Aside from meaningful use, the other two “pay-for-performance” models are the value-based payment modifidier and physician quality reporting system (PQRS). It was the guideline that led to how medical insurance reimbursements work and how electronic health records (EHR) were tasked with handling them as well as with private patient information. It essentially establishes a new framework that tries to emphasize value over volume by rewarding clinicians and streamlines other quality-reporting systems into a more thought-out system. As its big brother, it’s not necessarily making meaningful use obsolete, instead it’s meant to be a second layer of laws and policies especially since stage 3 of meaningful use for hospitals (which is moving towards value-base care, instead of “let’s just treat everyone and charge what we can”) in 2017/2018.
However, depending on what side of the bed you rolled off from, MACRA has different representations and for physicians, that means the new Advancing Care Information (ACI) program, which is meant to be a physician incentive program that will trigger increased or decreased payment adjustments starting in 2019. What this means is that in physicians will now be getting incentives to ensure that the patients they treat do not return. In public health, I believe the term is called “revolving door medicine”, in that often patients are treated as quickly as possible to alleviate the most severe problem at the time and sent back out to make sure that they are hitting certain quotas. The reason for this is multivariate but one factor is the low reimbursement from federal and state medical insurances so that medical groups, hospitals, clinics, private practices, you name it are trying to fit in more patients in order to make up for the hit to that day’s revenue because from my understanding depending on the services used, most insurance reimbursements are less than the actual cost of treatment meaning it’s a perpetual sinkhole of money. Once these patients are sent back out, for whatever reason something flares up again, and they return back for medical treatment which is promptly treated and thus rinse and repeat, as soon as they go out, they come back in like a revolving door.
This program is known as Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM) to help physicians be reimbursed not for the services that are rendered (hence why many times patients ended up doing multiple exams and diagnostics), but instead for the outcomes generated with treatment. Although the transition will be tough, this seems to be the way that medicine is going in order to move over to value-based care. When I spoke to a few physicians, they mentioned that MACRA is essentially rolling up stage 3 of meaningful use as the start of the MACRA rule and once again that it would be busywork of reporting the same things in different formats to different agencies. In fact, they mentioned that they would like a data repository that would allow them to push the needed data to a platform and then these agencies would have the vast data to work with themselves instead of relying on the physicians and administrators the hassle in having to work with that data. One thing that MACRA is going to require is the electronic reporting of quality measures but from a cursory look at the features, it seems that most EHR software aren’t actually set up to automate that reporting so now there is pressure on the software vendors to allow exporting data from the EHR into spreadsheets and prepared for electronic submission.
With quality measures being revamped, the physicians I spoke to are hopeful and skeptical at the same time that this can help with the mundane and silly metrics that were pretty arbitrary and weren’t actually informative in terms of providing better care or being more efficient. MIPS combines the HER incentive and reporting programs, including the Physician Quality Reporting System (PQRS) and the Physician Value-based Payment Modifier. In terms of the scores for MIPS, they are broken down into the “advancing care information” that I mentioned earlier, clinical practice improvement, and cost and quality management. To give a bit more detail about ACI, it’s meant to help providers select measures that they want to use in their EHR technology. However, this is all in speculation and it is still unclear whether or not it can achieve its goal of reducing provider burden. In essence if the organization, hospital, or whatever is providing patient care is able to fulfill these metrics, then they are able to earn a substantial financial incentive that only increases the longer they are fulfilling their benchmarks in quality patient care. On the otherhand, this also means that you can also be penalized by losing out on financial incentives through a negative payment adjustment. APM is the other payment track to earn financial incentives however it is a bit more exclusive to primary care and clinicians/groups who are part of risk-based models. It allows them to convert a large share of their Medicare/Payment Reimbursements to risk-based payment models which also get a payment adjustment bump too!
One thing is for sure though is that in order to ensure the smooth transition and efficient implementation of these programs, there has to be an alignment between the healthcare organization and its physicians. These programs allow simple and measurable criteria that are aligned with incentives, so it’s important that the relationship between hospitals and physicians allow them support each other and compliance with the rules. In doing so, it can help healthcare get to the point where data is following the patient to reduce gaps in care and information.