MACRA: A Physician’s Perspective

Physicians are quite honestly all over the place on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the legislation that permanently repealed the sustainable growth rate (SGR) formula that for years threatened to cut physician payments by about 20 percent, requiring annual congressional patches.

Congress needed to pay for this move, however, and one of the ways it did that was to limit annual increases to the Medicare Physician Fee Schedule to no more than 0.75 percent (generally 0.5 percent). This guarantees that until things are changed by a future law, physician pay increases are going to lag behind inflation.

The Quality Payment Program (QPP) is of course the other major provision of MACRA. The Merit-based Incentive Payment System (MIPS), which is part of the QPP, is designed to give payment bonuses to physicians who deliver high value and payment reductions to those who deliver low value. MIPS has been touted as a “revenue neutral” program, wherein the reductions pay for the bonuses. While the revenue neutral part is the equal shifting of payments from one provider to another, keep in mind that the total payment pool is effectively decreasing every year, after inflationary adjustment.

The QPP is a very complex program. Last year, Deloitte sponsored a survey in which 50 percent of physician respondents hadn’t yet heard of MACRA. Earlier this year, Healthcare Informatics published a study indicating that 34 percent of physicians were “not at all prepared” for MIPS. The other part of the QPP, the advanced Alternative Payment Model (APM) pathway, is even more complex than MIPS.

The Centers for Medicare & Medicaid Services (CMS) is using the first two years as a transitional period to get physicians used to the programs. CMS has been offering a ton of education, most of which is very good, but are physicians listening? I think they are trying to, but these programs are so complex that hand-holding will be required every step of the way.

From a coding and clinical documentation specialist perspective, the key is to ensure that Hierarchical Condition Categories (HCCs) are appropriately captured by physicians. All of the cost and many of the quality outcome metrics are risk-adjusted by these. CMS has also just proposed a patient complexity bonus for the second year of the program, also based on HCCs.

Helping your doctors capture accurate HCCs with the requisite specificity will only help their performance in the QPP.