The changing U.S. health care paradigm represents an intentional shift from volume (the more you do, the more you get paid) to value (the better quality you provide, the more you get paid). A seminal event responsible for this change was the Institute of Medicine’s report, “To Err is Human,” suggesting that between 44,000 and 98,000 Americans die from medical errors each year. This report prompted major questions about the quality of U.S. health care and its cost (nearly double most developed countries).
Together with an unsustainable rate of health care inflation, lawmakers have struggled to control health care expenditures, currently approaching $3 trillion or almost 18% of the gross domestic product. On April 16, 2015, the bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law. It aims to reimburse for better value (better quality at lower cost) through the Quality Payment Program (QPP). It represents an opportunity for the medical establishment to assume responsibility and accountability for improving quality and helping to control costs.
This article provides a practical explanation of MACRA and QPP and what they mean for practicing urologists.
MACRA accomplishes the following:
- repeals the highly criticized sustainable growth rate (SGR) formula
- changes the way that Medicare rewards clinicians, favoring value over volume
- streamlines multiple quality programs under the new Merit-Based Incentive Payments System (MIPS)
- provides bonus payments for participation in eligible Alternative Payment Models (APMs).
Clinicians have the option of choosing either MIPS or Advanced Alternative Payment Models (A-APM) track. A subset of the A-APM track is the MIPS-APM in which eligible clinicians (physicians, physician assistants, nurse practitioners) who participate in an A-APM but don’t meet certain thresholds receive credit within MIPS.
Excluded from participating in MIPS are physicians who are newly enrolled in Medicare, physicians who fall below the low-volume threshold, and those physicians significantly participating in A-APMs.