Making Sense of MACRA in the OB/GYN Practice

The arrival of the Medicare Advantage and CHIP Reauthorization Act (MACRA), now implemented by CMS as the Quality Payment Program (QPP) is just the latest attempt by federal officials since the dawn of Medicare to ensure broad-based coverage while reining in costs, according to a speaker at the 2018 Clinical and Scientific meeting of the American College of Obstetricians and Gynecologists (ACOG).

Charles Lockwood, MD, MHCM, senior vice president of University of South Florida Health and a professor of obstetrics and gynecology and public health, sprinkled a healthy dose of skepticism on whether MACRA will work, in his Saturday presentation to attendees in Austin, Texas. But he was clear that practices needed to be aware of the new rules. Rising healthcare costs are not sustainable, he said, and, “We are at a point where everyone is demanding change.”

He took the attendees through the complex reimbursement formula for the basic QPP tract, called the Merit-based Incentive Payment System, or MIPS, because he expects most obstetricians will use that option in the early going. But Lockwood warned there are many challenges with MACRA and the QPP, including:

(1) 40% of clinicians are exempt, because they don’t treat enough Medicare patients to meet thresholds to take part

(2) The program repeats the administrative burdens of earlier value-based purchasing programs while doing little to push consumers to pick high-value doctors

(3) Many practices will excel in the same areas of MIPS; if CMS sticks to its promise that reimbursement will create winners and losers, Lockwood said, then very small differences in performance will create large financial shifts.

He explained that MIPS calls for reporting in 4 areas—quality, cost (after 2019), advancing care information, and clinical practice improvement activities. In this last area, there are many areas to choose from, and most practices will "cherry pick” items where they excel. “It’s so easy that everyone is going to game the system,” he said. But the downside is that “tiny little changes will have a huge effect,” turning a 9% bonus can turn into a 9% penalty.

“Plus, it’s a lot of work to do this,” he said.

CMS wants to propel practices toward the second option under QPP, the advanced alternative payment model. Lockwood was blunt: “The idea is to make it so miserable [with MIPS] that everyone will want to move to an APM.”

Moving to advanced APM will require practices to meet Medicare risk and quality thresholds, and the entity will have to make payments to CMS if their actual expenditures exceed projected levels. Participants also must meet technology requirements, including those for certified electronic health records.

Another option being promoted under the new administration, he said, allows practices to join a “virtual” group for purposes of measurement. He outlined upcoming models, including 2-sided specialty risk models.

Despite the talk in the new administration of giving doctors more control over creating payment models, Lockwood is wary. While the Trump administration has promoted giving more authority to the Physician-Focused Payment Model Technical Advisory Committee, or PTAC, Lockwood said it matters who gets appointed to federal committees. Unfortunately, he said, the new administration has declined to appoint members who opposed the president in the 2016 election.

One doctor asked whether there would be more resources given to population health and prevention. Lockwood acknowledged this was the Obama administration’s approach, and the pressure on costs are going to continue in Medicaid. “Keeping people out of the hospital is a critical part of that,” he said. “But that would be an adult conversation. We can’t even have an adult conversation about who should run the VA.”

“Adult conversations,” as Lockwood called them, are desperately needed about end-of-life care, about when to use high-cost drugs, and when it makes sense in obstetrics to use expensive procedures to rescue extremely premature infants who, if they survive, will live with multiple health issues requiring ongoing care.

Lockwood believes that once practices move away from fee-for-services and are bearing more risk, “We’re going to make different recommendations to our patients.”