Health Policy Brief

Health Affairs Raises MACRA Implementation Awareness, Questions

April 05, 2017 12:14 pm News Staff

A March 27 health policy brief( produced by Health Affairs and funded by the Robert Wood Johnson Foundation provides an update on how implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) is proceeding nationwide.

As many family physicians are acutely aware, MACRA was signed into law on April 16, 2015, and its passage set into motion profound changes in the way the federal government will pay physicians moving forward.

The brief's authors point out that CMS now refers to the changes affiliated with implementation of MACRA as the Quality Payment Program (QPP).(

The nine-page brief is a succinct but thorough source of information for all physicians regardless of their familiarity with MACRA. The document begins with a quick history lesson detailing how Medicare payment got to this juncture.

"An overwhelming body of research in recent years has led to the conclusion that medical care in the United States is neither as efficient nor as effective as it could be," write the authors. "Inappropriate and excessive care is common, even as rising health care costs burden government, business and families."

Story Highlights
  • A new health policy brief from Health Affairs takes a deep dive into how implementation of the Quality Payment Program (QPP) is progressing.
  • The brief's authors give a brief history of the Medicare Access and CHIP Reauthorization Act (MACRA) and the QPP.
  • The brief provides an overview of the rules and regulations associated with QPP implementation and addresses key issues.

The unsustainable situation created a "growing momentum for change" built on increased accountability coupled with incentives aimed at improving care and holding down costs, the authors add.

The brief points out that in 2015 alone, Medicare paid U.S. clinicians some $130 billion. That amount represented 20 percent of total Medicare spending that year, say the authors.

Furthermore, CMS expects to pay out $3 billion in "positive payment adjustments" to physicians and other clinicians from 2019 to 2025.

Understanding the Rules

Importantly, CMS designated 2017 and 2018 as "transition years," write the authors. As part of that approach, physicians have some latitude in deciding the level at which they will initially participate; in other words, they can "pick the pace" that best suits their practice right now.

Many details about the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) program -- which includes advanced APMs -- are spelled out for readers in the brief.

And the authors note that changes were made in the final MACRA rule based on feedback from the AAFP and numerous other organizations.

"The MACRA final rule lowered the bar to form an advanced APM after overwhelming dissent from physician interest organizations on the stringency of the initially proposed rules," they write.

The policy brief also notes that a new committee called the Physician-Focused Payment Model Technical Advisory Committee was created specifically to guide and advise CMS on future APM policy.

Pros and Cons

The policy brief's authors ask some pertinent questions about key issues that continue to dominate the national conversation about the QPP.

For example, is the overall program design both coherent and workable?

The authors note that even though current regulations most certainly will be tweaked as the program matures, some strong dissent has already been expressed.

For instance, "Some critics say there's no clear evidence that current measures, or the scoring framework proposed by CMS, will provide anything close to a full and accurate picture of how well an individual doctor does in treating his or her Medicare patients," write the authors.

These same critics say paying individual physicians based on MIPS scoring is "flawed and irresponsible," and they favor dumping MIPS altogether and encouraging all physicians to join APMs.

In addition, some QPP critics reject the notion of attempting to change physician behavior through performance measurement and financial incentives, saying there is no evidence that these activities improve health care.

In response, CMS and some health policy experts argue that measuring performance can help physicians improve care and that the government has a "powerful fiduciary duty to spend tax dollars wisely."

The authors also explore the question of the QPP's value to solo, small and rural practice physicians. They note the government already has made revisions aimed at alleviating some of the concerns for these physicians.

In fact, according to the authors, CMS estimates that as many as 80 percent of clinicians in small practices across the country "will receive a positive or neutral MIPS payment adjustment in 2017 and 2018."

The research brief also puts forth for discussion additional questions about

  • government intrusion into the practice of medicine,
  • volume vs. value policies,
  • MIPS vs. alternative payment entities,
  • financial risk assumed by physicians, and
  • core measures that matter and make sense.

Moving Forward

The brief's authors note that "years of complex implementation lie ahead." They point out that the Trump administration could change current MACRA rules or even "seek changes in the law in Congress this year or in the future."

The debate continues as to the best ways to improve care quality, reduce unnecessary and wasteful care, and keep costs in control, they add.

"In the context of the history of the Medicare program, MACRA is but the latest experiment. It is a large one and will be closely monitored," say the authors. "Changes are inevitable, and the final rules create a formal pathway for continued stakeholder and public comment in coming years."

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