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Medical Home News: Thought Leader’s Corner

Medical Home News: February 2016, Thought Leader’s Corner

“MACRA is designed to establish an alternative set of predictable baseline payments to the old sustainable growth rate formula — and channel primary care physicians into either the alternate payment model (APM) or the Merit-Based Payment System (MIPS) track. Given the complexities of the two programs, and some real downside risk for some physicians, MACRA may have the unintended consequence of encouraging at least a few primary care physicians to stop taking Medicare altogether, retire from clinical practice, or organize a concierge practice.

But MACRA will cover everyone else. By 2019 the overwhelming majority of physicians will either be employed by hospitals, part of large group practices, or members of ACOs which meet the CMS APM criteria. This appears to make the APM track the easiest and least risky payment mechanism. The MIPS program appears to be more financially rewarding at first glance, with positive annual payment adjustments from 4 up to 12% as opposed to a 5% lump sum bonus on all Medicare payments from 2019 through 2024 for APM participants. But MIPs has complicated data requirements and has a significant downside, too.

Physicians who have a performance score at the mean of all MIPS-eligible physicians will receive no payment adjustment at all. Physicians who are below the mean will receive a negative adjustment on all claims the following year. Physicians who are in low-cost Medicare markets and may already be efficient may be compared to physicians in higher cost markets were improvements are easier to earn. Certainly this has been the experience of ACOs in the MSSP who have done better in high cost Medicare markets than efficient ones where the low hanging fruit has been already picked.”


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