What Does MACRA Mean for Health Officials?
In 2015, Congress passed the Medicare Access and Summary CHIP Reauthorization Act (MACRA), replacing the sustainable growth rate payment formula with a different approach to pay clinicians for the care they provide. This new legislation represents a significant shift to providers based on the quality and value of care they provide, rather than the quantity. MACRA went into effect at the beginning of January 2017.
Under MACRA’s Quality Payment Program, physicians are required to report specific quality measures in the Merit-based Incentive Payment System (MIPS) or participation in advanced alternative payment models (Advanced APMs). Advanced APMs are a model of care in which providers receive incentive payments for high-quality and cost-effective care, and also bear some risk related to patients’ outcomes. These changes affect Medicare Part B reimbursement for providers – depending on what program they participate in and their reporting, physicians could receive incentives, or in some cases face penalties.
There are a number of ways public health, and state health agencies in particular, is affected by MACRA. The first is MACRA requirements around electronic public health reporting.
The Medicare Electronic Health Record (EHR) Program, which is also called meaningful use (MU), has been modified for those participating in MACRA. MU had required providers to submit electronic data to immunization registries and submit electronic syndromic surveillance to public health agencies. Notably, under MACRA, all public health measures are now optional. The immunization reporting measure is prioritized in comparison to the other public health reporting measures in that it contributes to one of the reporting categories under MIPS, whereas other public health reporting measures are optional and contribute to bonus points, including syndromic surveillance, and electronic case reporting (starting in 2018).
While increased emphasis on immunization reporting is beneficial, there is some concern that the optional nature of the public health reporting might result in fewer clinicians submitting data in these areas. Dr. Harry Chen (VT-SHO) recently noted that “Ensuring electronic collection of these public health measures will allow state and local public health agencies to better monitor, prevent, and manage disease. We do not want to take a step backwards from the goal of healthcare providers and public health officials working together and sharing information to better serve the needs of the communities they serve.”
To address this concern, state and local public health agencies should work with providers and continue to emphasize the importance of the timely reporting of these measures for improving population health. However, this is only part of the work needing to be done– public health agencies must be ready to accept data from providers, which requires both technical capacity and administrative resources to make a reality. In fact, preliminary data from the 2016 ASTHO Profile Survey indicates that the majority of state health agencies receive MU-compliant messages from EHRs for syndromic surveillance (74 percent of respondents), electronic reportable laboratory results (84 percent of respondents), and immunization registries (90 percent of respondents). However, fewer have the capacity for bidirectional data reporting and exchange for reportable conditions and syndromic surveillance (approximately 24 percent and 26 percent, respectively). Last spring, CDC published guidance and recommendations for public health agencies readiness related to Meaningful Use Stage 2 and 3 and the public health measures. Many of these recommendations and resources are still relevant to this discussion.
MACRA also influences public health through the Advanced APMs. Since provider payment is tied to population outcomes, Advanced APMs typically prioritize quality improvement activities, team-based or coordinated care, and population health management. These population-based outcomes often require addressing the social determinants of health or other underlying issues, such as reasons for increased emergency department utilization or homelessness. State and local public health agencies are able to serve as a resource and subject matter expert to health systems who are considering investments in evidence-based prevention or other policies that address the social determinants of health. Further, there may be opportunities for state public health agencies to provide input on what population health outcomes are collected within Advanced APMs and identify areas of alignment with state health improvement plans or strategic planning within the state public health agency and Medicaid.
Given the change in the administration, it is unclear how MACRA will be influenced. Though this legislation passed with bipartisan support, larger potential changes in the Medicare program structure (e.g., moving to a premium support program) would likely have an impact.
Nevertheless, MACRA implementation is proceeding -- state and territorial health officials should consider how they will serve as a resource for health systems and support health systems transformation, particularly as physicians may have questions about how this legislation will affect them and how to report their participation. State public health agencies will need to continue investments in electronic public health reporting and, in particular, emphasize its value in the context of MACRA. For more information about MACRA and the role of state public health and additional resources, please see ASTHO’s factsheet.
Emily Moore, MPH, is a senior analyst for health transformation at ASTHO, where she supports state and territorial health agencies to advance public health through activities in payment and delivery reform, public health partnership with public and private payers, and population health improvement.