MACRA – doubling down on acronyms

19.05.2016
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Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide. Wait, what?

The Centers for Medicare and Medicaid Services (CMS) has felt your regulatory pain, apparently. They have watched you flounder in the muddy waters of ICD-10 and Meaningful Use. They have agonized with you over Quality Indicators. So, in an effort to “streamline” the “quality” metrics, and thus get a better handle on who is a good doctor and who is not, our wise legislators have come up a new, equally muddy law with the somewhat apocalyptic name MACRA.

MACRA stands for Medicare Access and Children’s Health Insurance Program Re-authorization Act of 2015. Here is how CMS describes it.

“Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs, including the Physician Quality Reporting System [PQRS], the Value Modifier Program, and the Medicare Electronic Health Record Incentive Program [meaningful use]. Through the law, Congress streamlined and improved these programs into one new Merit-based Incentive Payment System (MIPS).

So MACRA created MIPS. And QPP (Quality Payment Program). Oh, wait. MACRA created QPP. MIPS is a pathway under QPP.  The other pathway is APM (Alternative Payment Models). Clearly. Try to keep up, will ya?

Here’s CMS again:

The MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):

These proposed changes, which we’ve named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.

CMS continues:

Consistent with the goals of the law, the proposed rule would improve the relevance and depth of Medicare’s value and quality-based payments and increase clinician flexibility by allowing clinicians to choose measures and activities appropriate to the type of care they provide.

Wait, what? There’s about 100 things wrong with this sentence. MACRA does absolutely nothing to improve the relevance of the government’s “quality” indicators. The indicators are, for the most part, completely irrelevant to actual quality. The metrics are simply percentages of people who received a certain treatment or test deemed appropriate by large organizations like the AMA. Such percentages have little to do with the actual quality of the interaction between doctor and patient. And the flexibility mentioned is merely the flexibility to choose between MIPS and APM.  Which isn’t really a flexibility since APM billing pays more.
Clinicians who take a further step towards care transformation – participating to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS payment adjustments and would quality for a 5 percent Medicare Part B incentive payments.

What is and Advanced Alternative Payment Model? Bundled payments, meaning Accountable Care Organizations.  Remember those? Lump payments to a group of doctors, money that they keep if they spend less than the lump payment, but that they’re on the hook for if they spend more. CMS wants to funnel everyone into a bundled payment model. Not super flexible, those CMS folks.
OK, one last thing and then I’ll quit bugging you. Here’s the breakdown of the scoring for the incentive payment system:

10% – cost
50% – quality – based on six metrics
15% – clinical practice improvement (systems improvement, not personal improvement, I assume). 90 options to choose from!
25% – Use of EHR
To prove you’re a good doctor, you better use that EHR to document those quality metrics! Otherwise, CMS might take away your lunch money.

Image copyright: Steven Depolo, flickr, CC BY

Article last time updated on 24.05.2016.

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