The Medical Access and CHIP (Children Health Insurance Program) Reauthorization Act was passed in 2015 to provide a new framework for reimbursement of medical practitioners on a result-based approach as opposed to the number or volume of patient care. The new policy brought to an end the previous Sustainable Growth Rate Formula (SGR) which calculated payments for clinicians participating in Medicare based on volumes of patients treated. MACRA provides a program (Quality Payment Program) that acts as a tool not only to reimburse clinicians on merit but also bring improvement to health care services provided to patients ( Tikkanen & Abrams, 2019) . The model emphasizes value over volume. At the same time, the model is concerned with the use of EHRs (Electronic Health Records) by medical facilities, which is a way of ensuring that health care facilities not only offer quality health care services but also maintain an integrated database for patient information.
Summary of the Policy
The Quality Payment Program came into effect in January 2017 and allows participants of Medicare Part B to decide annually how they want to participate depending on their areas of specialization, location of operation, patient capacity, and the size of the facility ( Wendel, Serratt & O'Donohue, 2018) . Such an arrangement lets health care providers make decisions as regards the amounts they hope to earn through the provision of quality services to clients. The program has two payment track options; Alternative Payment Model (APM) or The Merit-Based Incentive Payment System (MIPS).
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The MBIP System improves the traditional (fee for service) method by adjusting payments according to the performance of a physician in a new reporting system. The system allows for the measurement of performance through the use of quality as a tool. The model consists of several existing and new elements of the Medicare reporting system including the Physician Quality Reporting System (PQRP), The Medicare EHS Incentive Program, The Value-Based Approach Payment Modifier Program, and the Improvement Activities. Participants in the plan are evaluated based on a compound score of four weighted categories; improvement activities, cost, quality and information advancement and cost at 15%, 10% 50% and 25% respectively for participants in 2018. Once a physician's score is obtained from all the four weighted categories, it is used to make adjustments to their Medicare earnings.
The second option for participants in Medicare Plan B under the Quality Payment Program is the Alternative Payment Method which is a risk-based approach between health care providers and payers. This method stipulates that participants receiving payments under this category bear a certain amount of financial risk, use the stipulated EHR technology, and meet quality measures similar to those used in the Merit-Based Incentive Payment Program, to meet the minimum requirement of the provision of quality services. The model gives incentives based on value and quality which is measured through different aspects such as more reward or pay for taking greater risk relating to a patient's outcomes.
Strengths of the MACRA
One of the greatest strengths of MACRA is the implementation of the Electronic Health Record which requires all medical practitioners to use data-integrated systems to record, store, and share relevant medical data. Over the years, one of the greatest challenges faced by the health care system in the United States is inconsistencies in patient data records ( Tikkanen & Abrams, 2019) . Data inconsistencies make it difficult for health care providers to store and retrieve accurate data especially where a patient receives care and treatment in different facilities. With the current trends in the world and especially in healthcare, MACRA has enabled hospitals to have an almost uniform system that enables them to share patient data between departments and hospitals easily while maintaining patient confidentiality.
Weaknesses and Challenges of the MACRA
Even though policies under MACRA advocate for quality of services and have stipulated guidelines on measuring and evaluating performance, the policy is incentive-based and it is not a requirement that all physicians have to join the Quality Payment Programs ( Tikkanen & Abrams, 2019) . The implication is that certain health care facilities may opt-out hence affecting the overall quality of health care services provided in the country. The second challenge is the fact that tools used in determining and measuring quality are not standard or pre-determined hence posing challenges in reimbursement of participants of the program. Measures such as patient experience, care coordination, appropriate use of services, total per capita measures, patient-reported outcomes, functional status, and Medical Spending Per Beneficiary (MSPB) are relative implying that they are not as accurate in measuring quality. The main goal of the Act is not only to implement a payment system that is based on the quality of services offered by physicians but to also ensure the proper functioning of the system and uniformity in services offered within the system. This can only be achieved if uniform tools and instruments of measuring quality are put in place. There is hence a need for a review of the standards used to measure quality by policymakers and other stakeholders.
Impact of the Act on Providers and Consumers
A major impact of the Act on health care providers is that they are reimbursed based on their performance. A quality-based approach, as opposed to the traditional fee for service payment, results in better services for consumers, while improving systems within the health care system ( Friedberg, Vargo, Rand Corporation & American Medical Association, 2018). The overall impact on the country's health care system is the attainment of the main goal of providing quality health care services to citizens as opposed to measuring health care achievement on the volume of patients treated.
Measures under MACRA emphasize patient-centered care. The Quality Payment Program focuses on the importance of collecting, reporting, and sharing patient data as well as the impact of care accorded to patients at an individual patient level as well as at the population level. The system advocates for the inclusion of all relevant stakeholders including the patient, members of the health care team, family members of the patient, and other health care providers. An integrated Information Technology by the Quality Payment Program allows for the flow of information between the patient and the health care facility as well as across the health care system with other health care providers. Such steps and partnerships between all stakeholders translated to an overall improved health care system allowing for utilization of resources and provision of quality care to patients. The final result is value for resources invested in the facilities and better health outcomes for the whole population.
In conclusion, various healthcare-related Acts and Legislations, for instance, MACRA, have been passed in the United States to improve the health care system and provide better quality and affordable services for all citizens. The United States, both at the Federal and National level allocates billions of dollars annually to the health care system (16.9% of GDP in 2018) ( Tikkanen & Abrams, 2019) . The use of the resources in meeting the needs of the people has posed challenges to the healthcare system hence leading to increased costs of health care in the country. MACRA provides a new effective framework for matching quality to payments accorded to physicians hence ensuring value for resources allocated to health care through the Medicare Program. The outcome is a healthier population, accountability for government resources (measured through elements of costs by physicians), quality services, and improved management of the health care facilities.
References
Friedberg, M. W., Vargo, C., Rand Corporation & American Medical Association,
(2018). Effects of health care payment models on physician practice in the United States: Follow-up study .
Tikkanen, R., & Abrams, M. (2019). U.S. Health Care from a Global Perspective, 2019 |
Commonwealth Fund . Commonwealthfund.org. Retrieved 4 May 2020, from https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019 .
Wendel, J., Serratt, T. D., & O'Donohue, W. T. (2018). Understanding healthcare economics:
Managing your career in an evolving healthcare system .
