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    MACRA changes physician reimbursement model

    The new “MACRA” system, underway as of January 2017, massively changes the way physicians are paid under Medicare and will impact pediatricians indirectly but substantially, say experts.

    The MACRA system is named for the 2015 bipartisan legislation “Medicare Access and CHIP Reauthorization Act,” which created the tsunami of change through Medicare, and basically just extended funding for the Children’s Health Insurance Program (CHIP) through fiscal year 2017.

    The Centers for Medicare and Medicaid Services (CMS) says MACRA’s “Alternative Payment Models” (APM) rules, developed with the clinician community, add incentives for high-quality and cost-efficient care: They can apply to “a specific clinical condition, a care episode, or a population.”

    Next: Medicaid mandates are final

    Deeper in the system’s second model of payment, the “Advanced Alternative Payment Models,” there is a multipayer component, explains Lindsey Browning, MPP, program director at the National Association of Medicaid Directors. In the out years, “If a provider is participating in Medicare APMs as well as participating in other payors’ APMs, it may help them receive that Medicare bonus under the program,” she says.

    One situation like this, Browning points out, would be where a pediatrician is part of a hospital system. That means a 5% Medicare Part B bonus for having a certain number of patients or percent of payments through the Advanced APMs. It is an indirect influence on some of the payment system reform happening in Medicaid, she says.

    Another part of MACRA will be an effort to increase electronic health records use, with systems pushing providers to meet the requirements. Also, in general, Medicare is such a huge payer that it has a big influence on other payers.

    In a June comment on what was then the draft rule, the American Academy of Pediatrics (AAP) said pediatrics would be most clearly impacted through the rules’ APM pathway as a Medicaid medical home. However, the AAP said, the CMS had provided an extremely limited opportunity for that. Such a Medicaid medical home can only qualify for the 5% APM payment if information technology is meaningfully used; quality structures similar to the Merit-Based Incentive Payment are implemented; and the practice is comparable to the officially defined medical home or bears some degree of risk. Those are highly problematic for pediatrics, the comments said.

    Browning says as the system continues to evolve, the question is how to move toward value-based purchasing while linking payment to quality measures that make sense for kids, adults, individuals with persistent mental illness, and others.

    The CMS published the final rule, the equivalent of perhaps 1000 standard pages, in the Federal Register on November 4, but added another comment period that ended on December 19, 2016.

    Reversal of MACRA is considered unlikely under the Trump administration, given the bipartisan support the legislation had.


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