Jones & Bartlett Learning Health Blog

    Lots of Focus on the ACA, Meanwhile MACRA Is Here to Stay

    Posted by Sophie Teague on Apr 5, 2017 3:24:30 PM

    While the recent headlines are focused on the potential repeal and replacement of the Affordable Care Act (ACA), another health care law is moving forward, unobstructed. The Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015 with full support from both sides of the congressional aisle.

    MACRA is a separate but complementary law to the ACA, according to Kristina M. Young, MS (SUNY Buffalo School of Public Health and Health Professions) and Philip J. Kroth, MD, MS (University of New Mexico School of Medicine). Young and Kroth are the authors of the new 9th edition of Sultz & Young’s Health Care USA.

    Ms. Young and Dr. Kroth explore the key features and major accomplishments of this important law in a one-hour webinar recorded on March 30th

    These two laws are separate but complementary with regard to movement from volume-based to value-based Medicare reimbursement, Young and Kroth explain.

    The major features of the ACA are that it promotes value over volume-based care; it expands coverage and controls costs through insurance marketplaces and Medicaid expansion; it defines the baseline of quality insurance; it promotes population health and prevention; and it incentivizes care coordination.

    MACRA also promotes value over volume-based care through the Merit-based Incentive Payment System (MIPS) as well as through Alternative Payments Models (APMs); Standardization of quality reporting metrics; the Reauthorized CHIP through 2017; and the shifts from Medicare fee-for-service to APM incentive models by 2018.

    “There were substantial elements of support and opposition to the ACA and as we know it passed by a very slim margin in congress with virtually no republican votes,” says Young.

    Unlike the ACA, MACRA received broad bipartisan support with its triple aim to increase patient satisfaction and quality, focus on population health, and manage costs. The aim of managing costs greatly appealed to Republicans in their traditional platform and approach. The Democrats on the other hand were pleased with the patient satisfaction and quality and population health goals of the bill.

    Kroth notes that the MACRA slogan seemed to be: ‘there’s something for everybody in this bill!’

    Because it had broad bipartisan support, it was much less controversial and even today there has been almost no media coverage of it, let alone any criticism. Both the Democrats and the Republicans including the new white house administration have signaled that they do not intend to repeal, replace, or change MACRA.

    So what is MACRA? Kroth explains that it’s based on the same set of core values or basic elements as the ACA – the idea being the government (either through Medicare or Medicaid) will pay for value instead of volume, based on measured quality outcomes.

    “Traditionally, if you’re a physician seeing patients, you get paid a fixed cost for that patient based on the disease they have and what you’re doing,” says Kroth. “If you see more patients and perform more procedures, you get paid more.  What they [Medicare/Medicaid] really want to pay for is better quality and make sure that if you’re going to do more that you’re actually providing better quality care.” Kroth, a practicing physician, goes on to explain that in order to incentivize physicians, “they withhold a portion of your payment and then they will measure the quality of care and in the future, they pay that back by either increasing the amount you receive or decreasing it based on the quality of the outcomes.”

    For example, for patients with diabetes, the measurement of Hemoglobin A1C in the blood is a simple lab test that measures a patient’s average blood sugar over time. So if a physician were to see 1,000 patients with diabetes, they would want to know what the average Hemoglobin A1C level was amongst those 1,000 patients, as that would be an indicator of how well that particular physician is controlling their blood sugar and therefore quality.

    The problem was that prior to MACRA, there were several government initiatives that had different quality measures.

    First, there was something called “Meaningful Use” which focuses on the use of Health Information Technology. Another program called PQRS or the Patient Quality Reporting System has a different set of reporting standards. Kroth gives the example of smoking: “In one government program you just report if the patient is smoking – yes or no. In the other government program, you report if the patient is smoking, but if they said no, did they quit recently, within the last 6 months, have they never smoked – there were many different answers. It was becoming very confusing to meet the requirements of various quality standards when there were so many different things that you had to report for the same item – like smoking.

    “So what MACRA did is it standardized the reporting of many of these quality metrics or measures to make it less complicated.”

    In the March 30 webinar, Kroth explains many more details about MACRA – MIPS vs APMs; the repeal of the flawed Sustainable Growth Rate (SGR) formula for Medicare physician reimbursement with AMA & other physician groups’ support (“Doc-fix”); the Republican’s concession of $200 Billion cost offset with Medicare providers’ spending reductions and cost increases for high-earning Medicare recipients; the Democrats concession of a 2-year (instead of 4-year) CHIP reauthorization, and more.

    Both Young and Kroth are reluctant to speculate on the future of the ACA but those participating in the webinar had many questions about it, given the republican’s recent attempts to repeal and replace the ACA with the American Health Care Act. Young's response was candid:

    “The projections of 24 million people losing health insurance in the next decade… We’re already talking about a congressional blood bath at the midterm elections. I think the one thing this did is that it did help elucidate what the on-the-ground features of the ACA are for the voters – the American public.

    We’re going to end up building off the principles of value versus volume health care – incentivizing physicians for quality – all the things that crossover between the ACA and MACRA but keeping in mind that this is a monstrous 3+ trillion-dollar system.

    We don’t turn the Queen Mary at a right angle on a dime. This is going to take years of deliberation and legislative activity in order to finally settle in as the way we finance health care.”

    Selected Sound Clips from the Webinar Q&A:

    On the Future of the ACA

    On Health Care as a Human Right

    On Insurers Pulling Out of the ACA

    On APMs vs. MIPS

    On Meaningful Use in MACRA

    On the Impact of Value Based Modifiers and Payment

    The full webinar is available at http://go.jblearning.com/MACRA. The new 9th edition of Sultz & Young’s Health Care USA is available at http://www.jblearning.com/catalog/9781284114676/. Instructors who want to consider the text for course use are invited to request a complimentary review copy.

    Topics: ACA, health administration, Kristina M. Young, MACRA, Philip J. Kroth

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