For long term and post-acute care (LT/PAC) providers there is a law lurking in the weeds of value-based purchasing (VBP) that is under no threat of “repeal or replace,” for it has the rare—for these politically charged times—support of both Republicans and Democrats: the Medicare Access and Chip Reauthorization Act (MACRA).

Signed into law by President Obama on April 16, 2015, after receiving more than 90 percent approval by both houses of Congress, MACRA implementation started just this past January.

The So-called ‘doc fix’

At its core, MACRA is a replacement for the Sustainable Growth Rate law, the long loathed but tolerated Medicare physician payment formula. The new law seeks to stabilize physician payments and move Medicare payments from fee for service (FFS) to VBP via a system built on Alternative Payment Models (APMs).

These APMs are the vehicles for providers—clinicians in the case of MACRA—to transition into a pay-for-quality, outcomes-based system through participation in such APMs as accountable care organizations (ACOs) and bundled payment arrangements.

Nothing is simple when it comes to health care payment systems, and MACRA is no exception. For instance, under MACRA’s Quality Payment Program there are two payment options for participating clinicians that must meet as of 2019. One is called the Merit-Based Incentive Payment System (MIPS) derived from traditional FFS payment, and the second comes under the APM heading.

MIPS works by arriving at a total number calculated for incentive payments under four new categories: Quality Measures, Resource Use, Advancing Clinical Information, and Clinical Practice Improvement Activities. To be excluded from the MIPS option, an eligible clinician must be enrolled in an APM.

Under the Centers for Medicare & Medicaid Services (CMS) regulation, these include the Medicare Shared Savings Program (MSSP) tracks 2 and 3, the Next Generation ACO Model, Comprehensive End-Stage Renal Disease Care, Comprehensive Primary Care Plus, or the Oncology Care Model.

There is much debate on how the Trump administration, specifically Tom Price, the medical doctor running the Department of Health and Human Services (HHS), could tweak APMs and MIPS in the coming months. For example, there is pressure from the medical community to relax reporting requirements, to get more physicians involved, and to allow more types of programs to qualify as APMs.

More Change to Come

To deflect some of the reporting pain for 2017, John Feore, a director at Avalere Health, a Washington, D.C., health care consultancy, says CMS installed a “pick your pace” option to slow the full implementation of MIPS, giving clinicians more leeway in which path they choose to pursue.

He says possible changes for 2018 could also address smaller physician practices.

“In the final rule last year, CMS increased the low-volume threshold that a provider would then be exempt from MACRA. So, the initial concern was the smaller practices would be the ones hit really hard because they wouldn’t have the infrastructure in place to do all the reporting,” Feore says. “But about a third of Medicare-billing physicians are exempt from MIPS because of the low-volume threshold.”

Regardless of the tweaking to come, Medicare will continue to move away from FFS.

 David Muhlestein, PhD“For MACRA, there really hasn’t been disagreement about whether MACRA should be in place. Now, moving forward, there will likely be pushback from those in the physician community, but it is not a national public issue; basically it is an agreed-upon thing, and the political discourse is focusing on other areas,” says David Muhlestein, PhD, vice president of research at Leavitt Partners.

The importance of MACRA to the overall VBP push is great, he says. The reasons are that the law affects all provider clinicians accepting Medicare payment, giving it a breadth that other initiatives lack; the fact it is legislation and not an administrative regulation; and, lastly, the fact that the law has bipartisan support, Muhlestein says.