Can MACRA Achieve Value-Based Reimbursement?

June 29, 2016


Fee-for-value payment: are we there yet?

With the plethora of value-based reimbursement models currently in use, it’s tempting to say yes. There are standards for fee-for-coordination, quality-based pay-for-performance, bundled payments, upside and downside sharing programs, capitation, and global payments. But these programs have a few significant flaws. Will MACRA (Medicare Access and CHIP Reauthorization Act of 2015) fill the gaps?

Defining Care, Patients, and the Physician-Patient Relationship

According to the nonprofit Center for Healthcare Quality and Payment Reform, MACRA addresses three key missing ingredients:

  1. Care Episode Groups: These groups define the types of services and procedures provided for specific diagnoses. They will identify physician-controllable services and costs specific to given conditions, instead of the amorphous “total costs of care” that are currently used.
  2. Patient Relationship Categories: These categories clearly identify the relationship a clinician has with a patient when providing a specific service. They will more clearly delineate responsibility for care quality and costs.
  3. Patient Condition Groups: These groups are based on a combination of a patient’s chronic conditions, current health status, and any recent surgeries or hospitalizations. They will enable more precise risk adjustment and acuity gradations than are currently achievable.

These are positive developments. However, the financial implementation of the two MACRA value-based payment programs (MIPS and APMs, described in “How to Create a Person-Centric Healthcare Payment Model” need to leverage that value. Currently, they are described as completely separate programs, neither streamlined nor consistent. They are not effectively clinician-focused and do not explicitly support care redesign. In fact, the associated administrative burden of MACRA requirements may force small practices to shutter or be acquired. How the programs will incorporate patient-friendly metrics and processes also remains to be seen.

Meaningful Use of Electronic Health Records

Meaningful Use has been an arguable aspect of value-based payment to date. Stakeholders have some strong feelings about how CMS should replace Meaningful Use with its proposed focus on “efforts to advance care information.” Fully 37 medical societies feel that current use of healthcare information technology should not be seen as a benchmark (PDF), and that CMS should move its focus from quantity of information exchanged to the quality and utility of that information.

A consumer advocacy group suggests that patients and caregivers be included as key exchange partners. The Association of American Family Physicians (PDF) and the College of Health Information Management Executives (PDF) agree, indicating that electronic health record (EHR) use should be patient-centric and should promote care coordination. One respondent even went so far (PDF) as to suggest that to more rapidly promote interoperability, CMS must focus its incentive program on IT vendors, not clinicians and their practices.

How will HHS respond to this varied feedback? We will begin to know on July 1, when the agency is scheduled to establish the initial EHR-related metrics for MACRA.

The realities of MACRA don’t yet live up to the promise of person-centric healthcare payment, as evidenced by stakeholder feedback from throughout the healthcare industry. No, we aren’t there yet, but MACRA is a major step in the right direction.

Back to June 2016