Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

To Prepare

Review the resources related to Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and meaningful use objectives.
Review the Criteria for Attestation.
Consider your current workplace or a former workplace and reflect on how EHR implementation slows your work, including staffing issues, medication barcoding, or any other issues that you might encounter. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Identify policy mandates and requirements and reflect on how informatics and EHR implementation affect your ability to meet those policy mandates and requirements.
Identify other mandates (e.g., quality, safety, requirement of reporting) and reflect on how they may affect issues you identified.
By Day 3 of Week 10

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Post a response that analyzes how policy mandates and requirements you experience might affect the issues you encounter as a practicing nurse informaticist. Be specific and provide examples. Next, analyze how evolving policies that may be implemented might affect issues you encounter in nursing practice, and explain why. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

McBride, S., & Tietze, M. (2019). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2nd ed.). New York, NY: Springer Publishing.
Chapter 1, “Introduction to Health Information Technology in a Policy and Regulatory Environment” (pp. 2–17)
Chapter 12, “National Standards for Health Information Technology” (pp. 272–295)

Centers for Disease Control. (2017, January 18). Meaningful use. Retrieved from
Lye, C. T., Forman, H. P., Daniel, J. G., & Krumholz, H. M. (2018). The 21st Century Cures Act and electronic health records one year later: Will patients see the benefits? Journal of the American Medical Informatics Association, 25(9), 1218–1220.
Office of the National Coordinator for Health Information Technology. (2017, May 15). Standard nursing terminologies: A landscape analysis. Washington, DC: Author. Retrieved from
Office of the National Coordinator for Health Information Technology. (2019, February 20). Meaningful use and MACRA. Retrieved from Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
Federal Register: The Daily Journal of the United States Government. (2016, May 5). Medicaid and Children’s Health Insurance Program (CHIP) programs; Medicaid managed care, CHIP delivered in managed care, and revisions related to third party liability. Retrieved from
eCQI Resource Center. (2019a, May 10). eCQMs. Retrieved from
eCQI Resource Center. (2019b, May 10). Eligible hospital/critical access hospital eCQMs. Retrieved from
Leapfrog Hospital Safety Grade. (2019, April 25). Leapfrog hospital safety grade: Scoring methodology. Retrieved from Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

In response to rising Medicare costs, Congress passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act in 2015. The law fundamentally changes the way that health care providers are reimbursed by implementing a pay for performance system that rewards providers for high-value health care. As of the beginning of 2017, providers will be evaluated on quality and in later years, cost as well. High-quality, cost-efficient providers will receive bonuses in reimbursement, and low-quality, expensive providers will be penalized financially. The Centers for Medicare and Medicaid Services will evaluate provider costs through episodes of care, which are currently in development, and alternative payment models. Although dialysis-specific alternative payment models have already been implemented, current models do not address the transition of patients from CKD to ESRD, a particularly vulnerable time for patients. Nephrology providers have an opportunity to develop cost-efficient ways to care for patients during these transitions. Efforts like these, if successful, will help ensure that Medicare remains solvent in coming years. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

chronic kidney diseasedialysisEconomic Impactnephrology
Medicare makes up approximately 15% of the federal budget and costs the Centers for Medicare and Medicaid Services (CMS) close to $700 billion in 2016.1 Although patients with kidney disease make up 11.7% of Medicare beneficiaries, they account for a disproportionate 28% of total Medicare costs.2,3 Furthermore, Medicare’s annual costs are projected to increase to $1.2 trillion in the next decade, most of it paid for by deficit spending.1 Although many factors contribute to the rise in Medicare spending, most health economists have argued that an underlying fee for service system has played a major role. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

To address Medicare’s rising costs, the government passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) in 2015.9 The law garnered bipartisan support (House: 392–37, Senate: 92–8), with policymakers eager to replace traditional fee for service, which rewards providers for volume of services, with value-based reimbursement.

Financial Risk and Fee for Service
Understanding the MACRA requires a brief digression. All patients face the unfortunate uncertainty of illness, which constitutes a major financial risk due to the high costs of health care. Insurance reduces this risk by paying for expensive care when it becomes necessary. These payouts are financed either by premiums (in the case of private insurance) or taxes and government borrowing (in the case of public insurance, like Medicare). Ultimately, patients and taxpayers end up shouldering the burden of increased health spending. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

In the traditional fee for service model, the financial risk of high-cost care falls squarely on insurers and thus, patients and taxpayers. As a result, health care providers face little to no risk, because they are generally paid at or above marginal cost for each service. Because the system rewards quantity over quality, health care providers have a strong incentive to overtreat patients, sometimes providing services with little concrete benefit or even harm. A recent study of Medicare fee for service care in hospitalized patients found that physician spending was highly variable but that more expensive providers had no better 30-day mortality or readmissions than less expensive providers.10 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Before the implementation of the ESRD prospective payment system, fee for service reimbursement for injectable medications likely led to the overuse of erythropoietin in dialysis. Despite a preponderance of randomized data showing that too much erythropoietin harms patients,11–15 dialysis providers continued to target inappropriately high hemoglobin levels in excess of contemporary guideline recommendations.16,17 Both the Medicare Payment Advisory Commission18 and the US Government Accountability Office19 argued that bundling payments would likely temper these rising costs and overuse. Because the prospective payment system bundled injectable medications into a single dialysis payment, there has been a dramatic decrease in erythropoietin use concurrent with a drop in death, strokes, and heart attacks.20 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Enter the MACRA
Before the MACRA, the government attempted to address the rising cost of care by imposing a strict cap on Medicare’s payments to physicians, known as the Sustained Growth Rate (SGR). As a blunt instrument, the SGR did not eliminate the incentive to overtreat patients, and it did not improve the quality of health care. Accordingly, it became the perennial target of physician and patient groups.21–24 In the years leading up to the MACRA, Congressional leaders repeatedly voted to postpone the SGR’s cuts in response to this criticism.

Eventually, Congress passed the MACRA, which replaced the defunct SGR with a system that rewards providers for delivering high-value health care. It does this by requiring providers to take part in one of two tracks: the Merit-Based Incentive Payment System (MIPS) or the advanced Alternative Payment Models (advanced APMs).9 Both tracks use a two-pronged approach to assess value in health care delivery: quality and cost. Rather than pay providers for rendered services, regardless of outcome, the CMS will financially reward providers who deliver high-quality, low-cost health care. By holding providers accountable, the MACRA effectively transfers financial risk from taxpayers and patients to providers. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Initially, the majority of providers will participate in the MIPS, because they will not have the infrastructure necessary to form an advanced APM.25 Under the MIPS, the MACRA assesses provider value through quality reporting measures (formerly known as the Physician Quality Reporting System) and episodes of care, which measure costliness (previously the Value-Based Performance Metrics). The program also requires that providers participate in clinical practice improvement activities and have an electronic health record (previously the Meaningful Use program). Performance along these dimensions is scored, and providers will receive bonuses or deductions: up to 4% of total payments in 2019, ramping up to 9% of total payments by 2022.25 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Quality Reporting under the MIPS
The quality performance category requires providers to report on six measures of their choice, including one outcome measure. The CMS will evaluate providers on their performance relative to their peers.26 Although >270 measures are available, only a few are specific to nephrology (Table 1). Because the CMS allows providers to report on any of the listed measures, nephrology providers have the option to report on non-nephrology conditions that are common to their practice, such as congestive heart failure, diabetes, and falls. However, doing so may not be advantageous, because they would be compared with providers who specialize in these other diseases. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

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Table 1.
Nephrology-specific quality measures under the MIPS

Furthermore, providers have the option to report as a group through a medical group’s tax identification number.25 Providers of large medical groups may find it beneficial to consolidate their reporting, mitigating the effect of outliers. Multispecialty group practices will also have the option to select their six best-performing measures across all specialties. As a result, poorly performing nephrologists in group practices might avoid reporting any quality metrics and depend on better performing specialties. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Nephrology providers with small volume practices (especially single specialty practices in rural areas) may find it difficult to adapt, because they will be unable to shield risk. The paucity of nephrology-specific metrics could accentuate these difficulties by forcing nephrologists to compete with primary care doctors and other specialists on non-nephrology measures. To address this concern, the CMS will exempt most providers with low patient or low payment volume from the MIPS.25 Additionally, starting in 2018, small practices with fewer than ten providers can consolidate with others to report as virtual groups. Still, many stakeholders, including the American Society of Nephrology, contend that additional quality measures need to be developed, particularly outcome-oriented measures.25,27,28 To ensure that the MIPS meaningfully promotes the health of patients with kidney disease, the nephrology community will need to work closely with the CMS to develop additional nephrology-specific metrics. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Episodes of Care under the MIPS
To assess provider cost, the MACRA mandates the use of episodes of care. An episode encompasses the treatment, aftercare (including postacute care), and complications associated with a specific clinical condition or procedure (Figure 1).29 For instance, an episode for AKI might include the initial hospitalization, outpatient follow-up and laboratories, and complications, such as a readmission for poor volume management. The episode would exclude clinically unrelated services, such as an elective hernia repair. By incorporating complications into the episode, the CMS will penalize providers who try to lower their costs by skimping on necessary care. Likewise, overly cautious providers with unnecessarily expensive treatment costs will also see decreases in reimbursement. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay

Medicare Access and Summary CHIP Reauthorization Act of 2015
Last year, Congress passed the Medicare Access and Summary CHIP Reauthorization Act of 2015
(MACRA), replacing the sustainable growth rate formula with a new approach to paying clinicians for the
value and quality of care they provide. This legislation aligns with the Centers for Medicare and
Medicaid Services (CMS) goals for value-based payments within the Medicare Fee-for-Service (FFS)
 Goal 1: 30 percent of Medicare payments are tied to quality or value through alternative
payment models by the end of 2016, and 50 percent by the end of 2018.
 Goal 2: 85 percent of all Medicare FFS payments are tied to quality or value by the end of 2016, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
and 90 percent by the end of 2018.1
On Oct. 14, 2016, HHS issued final regulations for implementing MACRA. The rule finalizes parameters
for MACRA’s Quality Payment Program (QPP), in which eligible clinicians (ECs) must choose to
participate in either the Merit-based Incentive Payment Systems (MIPS) or Advanced Alternative
Payment Models (Advanced APMs). The QPP changes how physicians and other eligible providers are
reimbursed for Medicare Part B claims and provides incentives for participation in quality improvement
Merit-Based Incentive Payment Systems and Advanced Alternative Payment Models
All clinicians who serve Medicare Part B beneficiaries must participate in the quality payment program
unless they bill less than $30,000 to Medicare and provide care to 100 or fewer Medicare patients per
year. If a provider is newly enrolled in Medicare during 2017, they are not required to participate in the
quality payment program that year. ECs must either choose to participate in MIPs or in an advanced
APM and report data to CMS. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
MIPS is a new program that combines several CMS quality programs, including the Physician Quality
Reporting System, the Value Modifier, and the Medicare Electronic Health Record (EHR) incentive
program, into one single program in which ECs will be measured on: quality, improvement activities,
advancing care information, and cost. The first payment adjustments based on performance in these
four categories will go into effect on Jan. 1, 2019, based on their performance in 2017. In order to help
implementation, CMS has allowed ECs to submit a test (e.g., minimum amount of 2017 data) of partial
or full year 2017 data for the first year. All ECs must submit some data, or else they will receive a
negative four percent payment adjustment. For 2017, the quality category for MIPS is most heavily
weighted, and the cost category is not counted (it will count beginning in 2018). For a full description of
the MIPS categories and measures, see the CMS web page.
Since the passage of the Affordable Care Act, many healthcare providers have been participating in
payment and delivery reforms that change how care is delivered and reimbursed, such as PatientCentered Medical Homes (PCMHs) and accountable care organizations (ACOs). MACRA builds on these
activities to further support participation in health system transformation. Clinicians participating in
Factsheet Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
APMs, such as PCMHs and bundled payment models, will receive credits under the clinical practice
improvement activities that contribute to their overall MIPS score.
Advanced APMs
ECs participating in advanced APMs as designated by CMS, would be exempt from MIPS payment
adjustments and would be eligible for an incentive payment. From 2019-2024, healthcare providers who
participate in advanced APMs would qualify for a five percent Medicare Part B incentive payment and
would be exempt from MIPS payment adjustments.
To qualify as an advanced APM, ECs must meet the following criteria: Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
1. Use of certified EHR technology.
2. Provide payment for covered professional services based on quality measures comparable to
those used in MIPS under the quality category.
3. Either (1) be a medical home model expanded under the CMS Innovation Center authority, or
(2) require participating APM entities to bear more than a nominal amount of financial risk for
monetary losses.2
Examples of APMs that meet the advanced APM criteria for 2017 include the comprehensive care plus
model and some ACOs such as the Medicare Shared Savings Program – Track 2 & 3 and the Next
Generation ACO Model.
3 CMS will likely add other models to the list of Advanced APMs over the next
few years.
Public Health and MACRA
MACRA legislation primarily affects physicians and other clinicians who receive Medicare payments as it
relates to how they are reimbursed for delivering healthcare services. However, public health
professionals are affected by MACRA in a few key ways.
Under the former EHR incentive program (commonly known as “meaningful use”), several public health
measures were previously required. In the new “Advancing Care Information” (ACI) category as part of
MIPS, these measures are now optional. Specifically, public health measures contribute to MIPS scoring Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay
as follows:
 The immunization reporting measure is optional and would earn the EC 10 percent of the ACI
performance score.
 ECs would earn a bonus point worth five percent for reporting one or more additional public
health reporting measures. These measures include syndromic surveillance, other public health
specialized registry reporting (including cancer reporting), clinical data registry reporting, and
electronic case reporting (starting in 2018).
While public health reporting may not be as incentivized under MACRA as it had been in meaningful use,
state public health officials and their staff can continue to support this reporting and demonstrate the
importance of collecting population-wide data for state and local health assessments to inform decisionmaking.
Access to healthcare and the quality of healthcare provided also has implications for public health and
health outcomes. Under MACRA, the movement from paying providers for the number of services
delivered to paying for quality or value continues. These changes to the healthcare delivery system and
reimbursement can be confusing for providers and patients. Public health professionals can provide
resources on these changes and answer questions. Further, they can collaborate with their colleagues in
health systems and Medicaid agencies to support quality improvement programs. In addition, many
state public health agencies are engaged in State Innovation Models (SIM) activities. As part of SIM,
states have pursued payment and delivery reforms and invested in infrastructure and capacity building,
which may align with MACRA. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Essay