Do the terms MACRA, MIPS or APM mean anything to you? If not, you should know there is a clock ticking, and your practice might be in for some big financial losses if you don’t act soon.
MACRA: Medicare Access and CHIP Reauthorization Act of 2015
MIPS: Merit-based Incentive Payment System
APM: Alternative Payment Models

We know you probably didn’t go to medical school because of a fondness for acronyms or governmental health legislation, but it is especially important that you understand MACRA and its components MIPS and APM. This is because data submitted by your practice this year (2017) will be used by the Centers for Medicare and Medicaid Services (CMS) to determine penalties and bonuses that go into effect in 2019.

“Why is the government doing this to me?”

That is one of the most common questions heard by Gregory J. Esper, MD, MBA, a neurologist and MACRA expert who spoke at the 2017 meeting of the American Academy of Neurology. CMS has a problem, he says. Medicare and Medicaid enrollees are increasing every year, and health-care costs are growing without improvements in quality.

“We have a Medicare trust fund that is going to be insolvent probably by the late 2020s,” he says. “So the government says we are going to transition to value-based payments. Value is quality over cost. They are going to ask us to do the highest quality work for the lowest possible cost.” This is the motivation behind their MACRA program, which will require practices to submit patient care data either through a MIPS or an APM. The data will then be used to determine reimbursement penalties and, in some cases, bonuses. To learn more, check out the AAN’s side-by-side comparison chart showing the differences between MIPS and APM.

“Does the potential repeal and replacement of the Affordable Care Act relieve physicians of the need to think about MACRA’s effect on their practices?”

This is another question Esper hears, and the short answer is “No.” “Even if they repeal the ACA, MACRA will stay,” he says. “The reason is that MACRA is separate legislation from the ACA.” The Affordable Care Act paved the way for MACRA, and you can see that in its components. Some are based on programs you may already be familiar with like the Physician Quality Reporting System (PQRS) and the Electronic Health Record Incentive Program (aka meaningful use).

“So, what kind of penalties are we looking at?”

Esper answered this question at the AAN meeting by mocking up MACRA’s effect on a hypothetical three-physician practice, with 28 percent Medicare volume, and an annual revenue of $1.5 million. From 2019 to 2025, this practice also hypothetically increases its revenue by 1.6 percent per year.

“If you do nothing at all, in 2019 the payment adjustment is -4% [for a total revenue penalty of $16,800 in the case presented above] and -9% by 2025 [for a total revenue penalty of $52,803 in the case presented above]. This is money you are leaving on the table if you don’t participate in MACRA.”

These figures give you some perspective, but will be different for every practice. The more Medicare and Medicaid patients you see in your practice, the sooner and more deeply MACRA will affect you. But, says Esper, where Medicare goes, most private insurances follow, so it is in your best interest, whatever your practice makeup, to understand this.

An easy place to start is with these four short videos on the AAN’s YouTube Channel. You can also access many more resources on the AAN’s MACRA page or the Centers for Medicare and Medicaid Services’s MACRA page.