What Spine Specialists Need to Know About MACRA

Commentary by Cheryl Zapata, CDO Texas Back Institute

Peer Reviewed

Proposed rules for the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) were published in April 2016 by the Centers for Medicare and Medicaid Services (CMS). MACRA ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments as CMS moves forward with the new value-based payment model.
man confused and going through a maze“MACRA was written to measure quality improvements in patient outcomes". Photo Source: 123RF.com.This new Quality Payment Program (QPP) outlines a system that is designed to reward those physicians who give better, more accessible care instead of simply, more care. Hospitals and ambulatory surgical centers are not included, nor are physicians or physician groups that bill $10,000 or less and have 100 or fewer Medicare patients.

“MACRA was written to measure quality improvements in patient outcomes. Unfortunately, many of the measures proposed do not apply to specialists,” Cheryl Zapata told SpineUniverse. “We will have to wait until November of this year when the CMS comes out with the final regulations to see if additional specialty measures are added.”

MACRA is due to start on January 1, 2017. However, CMS acting Administrator Andy Slavitt recently told the Senate Finance Committee that a delay is possible due to the overwhelming response from the public. The concern was about those individual and small group physician practices that would struggle with the time and cost constraints of the implementation.

MACRA Payment Basics

MACRA has two payment tracks, the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). The start of payment under the new QPP will begin January 1, 2019, based on data starting January 1, 2017 (unless this date is delayed). A 0.5% annual increase in reimbursement is approved for 2016-2019 for all physicians.

According to Medicare, approximately 92% of eligible clinicians initially will fall into the MIPS track. “Most spine specialists will opt into the MIPS track, although some may choose to take a penalty. Currently, there are no APMs that include spine specialists,” she said.

MACRA has three requirements for qualification as an APM:

  1. EHR technology must be used by participants.
  2. Clinician pay is based on quality measures similar to those in the quality category in MIPS.
  3. Participate in a risk-sharing arrangement: “bear more than a nominal amount of risk for monetary losses,” according to the CMS.

Specific models that qualify for the APM track include patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and next-generation ACOs. The incentive for participation in the APM track is a 5% lump sum payment (in 2019-2024) of the previous years' Medicare part B payment.

MIPS Compared to Current Pay-for-Performance

MIPS consolidates the existing pay-for-performance programs and eliminates the current penalty structure at the end of 2018. The new MIPS payments will be based on a performance score calculated from the four weighted categories listed below.
MACRA TableThe performance score will be from 0-100 and compared to an established mean or median of all MIPS participants' scores called the performance threshold (PT). Scores above the PT will receive bonuses and below will receive penalties.

Improving Care Coordination

Improved interoperability to facilitate the exchange of information between healthcare systems is a major focus of MACRA. “Specialists will need to improve their care coordination with primary care groups and hospitals.  This could prove to be very difficult as EHR systems don’t integrate easily,” Cheryl Zapata commented. The ability to exchange patient information is also crucial in chronic illness where many seniors have multiple diseases and caregivers. According to Senator Ron Wyden, 75% of Medicare spending comes from seniors with four or more chronic illnesses.

The Future

Many physician specialty organizations are calling for changes to the proposed MACRA rules, including:

  1. Delay the January 1, 2017 start date.
  2. Expand access for specialists to APM’s.
  3. More quality improvement measurements for specialists.
  4. Regional and national technical assistance.

“MACRA will transform health care and significantly impact the care we give our patients. Now is the time to make the appropriate changes to mitigate disparities for specialists,” she concluded.

Updated on: 05/04/19
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Cheryl Zapata
Chief Development Officer
Texas Back Institute
Plano, TX

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