HPC Corner: MACRA 2018: Skeptics Fret, CMS Perseveres

HPC Corner: MACRA 2018: Skeptics Fret, CMS Perserveres
Bill Donovan, MD, MPH, FACR
Let’s review: MACRA was passed in mid-2015. It took CMS a year to actually craft rules and regulations to implement the legislation. In brief, physicians were incentivized to join Alternative Payment Models for greater bonuses, those maintaining a fee-for-service business report under MIPS, and a small percentage were exempted, in the case of low-Medicare volume practices. After delay in implementation of some components, and easing of others, CMS is scheduled to start imposing bonuses and penalties in 2019. This was, and is, an aggressive timeline — not just for physicians, administrators, and CMS itself — but for thinktankers as well.


Amongst the latter group: in its June 2017 report to Congress, MedPAC (the Medicare Payment Advisory Commission, probably the highest-profile organization advising Congress on overall Medicare policy) expressed severe doubts that the MIPS portion of MACRA could succeed in improving health care quality, physician performance, or in lowering costs. Amongst their arguments: the metrics don’t actually measure quality, many metrics are self-reported, other metrics are not under MD control, and the administrative burdens are too expensive and time-consuming.


In February 2018, Health Affairs magazine (in their blog) called for outright elimination of the MIPS program. (It was co-authored by Paul B. Ginsburg of the Brookings Institution, now a MedPAC commissioner, and a gadfly who has advocated for payment overhaul for nearly 30 years). The authors called for improved and expanded incentives for APM participation.


In its March 2018 report to Congress, MedPAC took its own doubts a big step further, also calling for the elimination of MIPS. MedPAC proposed a “Voluntary Value” program to replace MIPS, taking the spotlight off the individual physician and instead assessing real or virtual MD groups based on larger populations of patients, and what they see as better or more meaningful population-based metrics. It also proposed capping payment penalties at 2%.


Dr. Gail Wilensky — economist, CMS director from 1990–1992, and the first MedPAC chair from 1997–2001 — now weighs in with a perspective in the 4/5/18 NEJM. It’s brief, accessible, and there’s also a 10-minute audio download interview. She acknowledges the difficulties inherent in how MIPS is currently designed, and sympathizes with frustrated providers. But she questions MedPAC’s call for cessation of MIPS as politically unrealistic (literally requiring an Act of Congress to amend MACRA), and that their ‘Voluntary Value’ program is sketchy and untested. She does venture that maybe the CMMI (Center for Medicare and Medicaid Innovation) should pilot-test it.


Will respected economists and inside-the-beltway types help bend the MACRA curve? Congress is likely immobile this year, but CMS could choose to amend their regulations and implementation schedule further. Look for ACR MACRA Committee Chair (and ASNR HPC Committee Co-Chair) Greg Nicola to lead analysis of any new rulemaking from CMS.


Action items:
  • Fill out RUC surveys when your receive them — the Relative Value System is alive and well, and will likely guide payment for many years to come. ASNR remains engaged and busy at CPT/RUC. RUC reps Greg Nicola and Melissa Chen are presenting 15 CPT codes for re-valuation at this month’s meeting, including spine CT;
  • Maintain your memberships in ASNR, AMA, and ACR so that we can continue representing your interests at CPT, RUC, and to CMS regarding payment reform;
  • Attend the Economics sessions at ASNR 2018 for the latest updates!


  1. Medicare Payment Advisory Commission. Medicare and the health care delivery system. Report to the Congress. June 2017, March 2018.
  2. Medicare Payment Advisory Commission. Medicare payment policy. Report to the Congress. March 2018.
  3. Wilensky, GR. Will MACRA improve physician reimbursement? N Engl J Med 2018;378:1269-71, 10.1056/NEJMp1801673.
  4. Fiedler M, Gronniger T, Ginsburg P, et al. Congress should replace Medicare’s merit-based incentive payment system. Health Affairs. 2018; 10.1377/hblog20180222.35120.

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