This was supposed to be the first year of data collection for the Medicare Access and CHIP Reauthorization Act (MACRA), a federal law creating sweeping changes in Medicare physician reimbursement. But, faced with criticism over the proposed timeline, the Centers for Medicare & Medicaid Services (CMS) decided to offer participants considerable flexibility in 2017. Even practices that have not put effort into MACRA so far can avoid a 4% reimbursement cut in 2019.

Federal officials call it the “Pick Your Own Pace” program, and the bare minimum allows reporting on just a single data point for 1 patient. “This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more,” then–CMS Administrator Andy Slavitt wrote in a blog post last year.

“You can just wait until December 31 and report the blood pressure of 1 patient that day, and as long as you submit it before March 31, 2018, you will dodge the cuts,” explains Michael Marron-Stearns, MD, CPC, a compliance consultant based in Austin, TX. “I know that sounds bizarre, but I actually confirmed it with the CMS.”

It is not yet clear whether 2018 will be another transition year or whether it will require full participation, Marron-Stearns says. But it will get harder to avoid progressively steeper Medicare cuts as the years advance and the program scales up, he adds.

Payment Models
The goal of MACRA is to transform Medicare from a fee-for-service model of reimbursement to a value-based one. Providers and health care organizations report on various criteria and receive penalties or bonuses accordingly.

If it is your first year accepting Medicare patients or you receive less than $30,000 a year in Medicare reimbursement or treat fewer than 100 Medicare patients, you are excluded from MACRA. CMS estimates that 41% of providers will be excluded.

Physicians subject to the law will fall into 1 of 3 payment groups: the Merit-Based Incentive Payment System (MIPS), the Alternative Payment Model (APM), or the Advanced Alternative Payment Model (AAPM).

Physicians in most APMs will still receive a MIPS score, but they will share that score with all the other providers within that organization. Only physicians in an AAPM can avoid getting a MIPS score. However, only about 4% of physicians currently belong to organizations that qualify as AAPMs, according to CMS. Hence, the majority of physicians will receive a MIPS score.

A MIPS score ranges from 0 to 100 and will be calculated based on 4 categories of performance:

• Quality of patient outcomes
• Use of electronic health record (EHR) technology
• Clinical practice improvement activities (eg, expanded hours)
• Cost containment

To calculate the score, each category will be weighted differently as the years progress. For example, in 2017, cost containment will not be weighted at all but eventually will account for 30% of the score. In addition, although quality of patient outcomes will be weighted heavily in early years, it will count for less as the program unfolds.

Included in APMs that are not advanced are accountable care organizations (ACOs) in Medicare Shared Savings Program Track 1 (in other words, most ACOs) and Oncology Care Models that do not accept downside risk.

Physicians in an APM gain streamlined reporting requirements and automatically receive more favorable scoring on measures of patient outcomes quality, practice improvement, and EHR use compared with independent practices.

AAPMs include ACOs that take on substantial downside risk, such as Next Generation ACOs, as well as risk-bearing models such as Comprehensive End-Stage Renal Disease Care Organizations. AAPM physicians receive an automatic 5% payment bonus from 2019 to 2024 and do not have to report patient outcomes, use of EHR technology, or clinical practice improvement activities. How much of that “substantial risk” will come out of physicians’ salaries depends on how each entity is structured: it could be a lot, or it could be nothing.

AAPMs are viewed as the smartest financial bet for Medicare-heavy practices, but, at this point, most, if not all, have closed their enrollments for 2017. “A lot of the options are already off the table, especially the ones for smaller primary care physicians,” says Jeff Clough, MD, assistant professor of medicine at Duke University, who has studied and written about MACRA.

Economies of Scale
There is a widespread belief that the MACRA compliance burden will fall heaviest on smaller practices, which lack the administrative infrastructure of large health care organizations. Indeed, many believe one of the goals of the law is to encourage small practices to join larger systems. “The designers of the law are probably hoping that costs will be brought down by more and more physicians moving into APMs,” says Clough. However, he adds, little evidence suggests that larger organizations operate more efficiently than smaller ones.

Unlike the Affordable Care Act, MACRA enjoys widespread congressional support and is unlikely to be repealed or replaced any time soon. “We are complying because it is the law,” comments Louis Goodman, PhD, executive vice president and CEO of the Texas Medical Association. But he fears MACRA might end up adding to physicians’ administrative and staffing burdens without doing much to improve patient outcomes or cost containment.

Nevertheless, he says he is glad CMS offered the “Pick Your Own Pace” program this year and hopes CMS will continue to offer flexibility in 2018.