Alexander Misono, MD, MBA
Chair, SIR RFS Advocacy Committee
R4 Massachusetts General Hospital
Questions and Answers
Why should residents/fellows pay attention?
MACRA will impact the way every physician is paid. Trainees who understand MACRA and related changes will be valuable assets to their programs and future employers.
What is MACRA?
MACRA is the Medicare Access and CHIP Reauthorization Act, and it is now law. Under MACRA, Medicare will be transitioning from a volume-based to a value-based payment system.
What is meant by “value-based” payment systems?
Traditionally, doctors have been paid for performing tasks related to patient care (e.g. procedures) based on volume (e.g. number of procedures performed). This is called “fee-for-service.” In contrast, value-based payment systems de-emphasize volume and instead reward providers who provide higher quality care. Fee-for-service is being phased out.
Isn’t MACRA just for Medicare payments?
Yes, MACRA is being instituted by CMS for Medicare payments. However, we know from past experience that private insurers often take CMS’s lead when it comes to payment. Therefore, these models are likely to proliferate. Furthermore, with an aging population, Medicare payments will continue to grow as a proportion of providers’ payment pools.
By what mechanisms will MACRA be enacting change?
MACRA brings together a number of existing approaches and efforts under one umbrella, deemed the Quality Payment Program (QPP). The QPP introduces two distinct payment models: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)
What is MIPS?
The Merit-Based Incentive Payment Systems (MIPS) is designed to reward and penalize providers based on their performance along several key metrics. These metrics include quality, meaningful use, clinical practice improvement, and cost/resource use. Depending on overall performance, providers may receive more, the same, or less payment for services rendered. Furthermore, providers’ scores will be available for public viewing in the future.
I heard this is all “budget neutral.” What does that mean?
Some providers will “win” while others “lose.” In other words, bonuses for good performance will be paid for by penalties for poor performance. You will, in fact, be directly competing with other providers for quality grades and, therefore, financial rewards. The bonuses and penalties will change over time; in 2020, for example, the maximum possible bonus will be 15% and the maximum possible penalty will be 5%.
What are APMs?
Alternative Payment Models (APMs) are an umbrella term to describe various new payment models that are no longer based on a fee-for-service construct. One of the most well-known acronyms in this space are accountable care organizations (ACOs), which bring together providers and health systems to coordinate care for patients. All of these new payment models shift risk to providers and health systems who stand to benefit or lose based on the efficiency and quality of care delivered.
The expectation is that physicians will adopt MIPS initially, with APMs becoming increasingly adopted over the next decade. Physicians who participate in APMs would be exempt from the reporting requirements of MIPS, as APMs provide their own incentives for performance. By 2020, the expectation is that 85% of government healthcare expenditures will be funneling through APMs.
What does this mean for me?
While exact mechanics continue to be worked out (especially as they relate to a highly specialized field such as IR), MACRA will definitely impact the way you are compensated in the future. Furthermore, measurement begins in 2017 (which is next year!), so essentially all trainees will be entering practice with MACRA already in active play. Trainees with an understanding of payment reform will likely be valuable to their future practices.
It is worth noting that first-year clinicians entering their initial year of Medicare Part B participation are exempt from reporting on MIPS, with a few exceptions.
How do I get involved?
- Get active with the SIR RFS and join the Advocacy Committee, which has multiple ongoing projects directed at enhancing the future of IR advocacy.
- Join SIR Grassroots Advocacy efforts by traveling to Washington, DC and advocating on behalf of IR on Capitol Hill.
- Support advocacy efforts of the SIR by donating to SIRPAC.