Entering an Era of Uncertainty: 11 Ways to Prepare for MACRA

Between the release of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule and the election of a president who has promised to repeal the law that laid the groundwork for MACRA’s Quality Payment Program (QPP), uncertainty may be the only sure thing in U.S. healthcare today. Regardless of what happens to the Affordable Care Act (ACA), or to MACRA, cardiologists should begin preparing for changes in how they deliver care and are reimbursed for their work.  

Season of change

A lot of rules changed in the fall of 2016. In October, with the release of the MACRA final rule, the Centers for Medicare & Medicaid Services (CMS) detailed when new payment models would be rolled out and how they would reward clinicians for the value, rather than the volume, of their patient care.  Less than a month later, Donald J. Trump—who had promised to repeal the ACA—won an election that seemed to rewrite the rules of politics. Physicians, policymakers and health journalists are speculating about what healthcare will look like under President Trump, with tweets like this one from Modern Healthcare’s managing editor: “#MACRA (bipartisan) is entwined w/ the #ACA. Does that mean Congress has to keep pay/delivery reforms in ACA or scrap big parts of MACRA?”

We don't know the answer to this or the many other questions that could reshape our healthcare system, but we do know that implementing Medicare’s QPP—or any new payment models, regardless of what they may look like in the future—will present challenges and opportunities for the cardiovascular community. SCAI is advising its members to consider the following 11 steps, whether MACRA continues or is replaced.

1. Check your specialty designation with CMS. If you are an interventional cardiologist, ensure that CMS has identified you as such so that when the inevitable assessment and comparisons of resource consumptions begin, you will be compared to other interventional cardiologists.

2. Meet with your practice/hospital administration as soon as possible. Assuming that the QPP (or major components of it) will continue,  work with your practice/hospital administration to identify steps you need to take to comply with MACRA and agree on a timeline for implementation. When you begin submitting data to QPP will help determine how much your 2019 Medicare reimbursements will be adjusted, ranging from a negative 4 percent adjustment to a “moderate positive adjustment."

3. Consider your reporting options. Again, assuming the QPP will continue as detailed in the final rule, analyze the pros and cons of reporting your data as an individual or under the umbrella of your practice. You will be able to choose among individual and specialty-specific measures.

4 Determine whether you are already participating in any of the QPP’s advanced alternative payment models (APMs), or if you meet the threshold for participating in an advanced APM. If you qualify for an advanced APM, you could earn a 5 percent Medicare incentive payment from 2019 through 2024 and might be exempt from certain reporting requirements.

5. Study your (or your practice’s) Medicare charges and the number of Medicare patients you treat. CMS listened to the concerns of SCAI and others about the possible impact of MACRA on small practices. If you submit less than $30,000 per year in Medicare charges, you may be exempt from the Merit-based Incentive Payment System (MIPS) in 2017.

6. Review the QPP’s accommodations for small, rural and non-patient-facing practices. CMS agreed with SCAI and others who advocated for performance reporting options that to make it easier for practices meeting certain  specifications to qualify for incentives.

7. Enroll in a qualified clinical data registry (QCDR) to streamline reporting processes.

8. Evaluate your options for reporting quality data. Your choices include claims, electronic health records (EHRs), QCDRs or the group practice reporting option web interface. Each option has pros and cons.

9. Familiarize yourself with the QPP’s rules for clinical practice improvement activities (CPIAs). You may already be participating in initiatives that qualify as a CPIA, or you may need to make adjustments to your current quality-improvement efforts to fulfill this requirement.

10. Ensure your EHR is secure and uses certified EHR technology (CEHRT). You may need confirm with your EHR vendor that its products support new payment model adoption.

11. Watch for changes. Even if the Trump administration makes no changes to MACRA, it’s likely that CMS will update the regulations based on feedback from users. Monitor for such changes as well as webinars and communications from SCAI and others in the cardiovascular community.

Osvaldo S. Gigliotti, MD, and Dmitriy N. Feldman, MD, are interventional cardiologists at, respectively, Seton Hall Institute in Austin, Texas, and Weill Cornell Medical College, New York Presbyterian Hospital in New York City. They serve as chair and co-chair of SCAI’s Advocacy and Government Relations Committee. They thank SCAI’s 2016-17 president-elect, Peter L. Duffy, MD, MMM, for contributing to this article.