MACRA: New Incentive-Based Physician Pay Program

In the coming months, the Centers for Medicare & Medicaid Services (CMS) will begin implementing a 2015 law that changes how doctors who provide care to Medicare beneficiaries are paid. ASN is working with CMS to help the Agency get the new system —which aims to reward value over volume—right for nephrology clinicians and the patients with kidney disease they serve.

Last year, Congress repealed and replaced the Sustainable Growth Rate (SGR), the outdated physician payment system that called for substantial annual cuts to physician reimbursement, by passing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

“One thing everyone agrees upon in Washington was that the old payment system was broken, and ASN advocated for its repeal and replacement. The new payment system aims to move healthcare in the right direction, emphasizing quality of care instead of quantity of care and reducing administrative burdens so physicians can focus their efforts on providing the highest quality of care to patients,” said ASN President Raymond C. Harris, MD, FASN. “ASN delivered nearly 20 pages of recommendations concerning how to improve and successfully implement the new system and achieve the goals Congress outlined when it enacted MACRA.”

The new payment system—termed the Quality Payment Program—will offer two tracks for Medicare physician payments: MIPS (Merit-based Incentive Payment System) and APMs (Alternative Payment Models) (Table 1).


On June 27, 2016, ASN submitted extensive recommendations to CMS regarding its 962-page proposal for putting in place the significant changes called for by MACRA. CMS is expected to issue a final rule on MACRA implementation in the fall of 2016, taking into account input from ASN and other stakeholders. The society emphasized several key themes, described here:

Delay the start of data collection

MACRA requires that the new Quality Payment Program take effect starting January 1, 2019. Although CMS proposed to start collecting data on physicians’ quality of care, resource use, and other aspects of care starting January 1, 2017, ASN believes that an additional six-month period is needed to educate clinicians. The society recommended that CMS delay the start of the performance period until July 1, 2017.

ASN believes that clinicians will need this time period to familiarize themselves with the final rule and prepare their practices to deliver the best patient care possible in the new payment system. The society urged CMS to develop a robust educational program to help clinicians—especially nephrologists, given that they treat patients with varying degrees of sickness and complexity in multiple types of facilities—approach the pathways available in the Quality Payment Program. ASN also intends to complement and amplify educational programs developed by CMS with its own educational tools.

The delay ASN proposed (to July 1, 2017) would allow clinicians time to come up to speed and to review their data before their payments start to be adjusted on January 1, 2019.

Factor in how patients with kidney disease are unique

Throughout its 19-page commentary to CMS, ASN emphasized the complex needs of kidney patients and their status as among the most vulnerable in the entire Medicare program. Kidney disease disproportionally affects underrepresented minorities, and patients with advanced kidney diseases suffer from multiple other serious chronic co-morbidities, including diabetes, hypertension, peripheral vascular disease, and heart failure. More than 50% of patients with CKD have 5 or more other co-morbid conditions, and CKD care for patients age 65 and older exceeded $50 billion in 2013—representing 20% of all Medicare spending in this age group.

ASN also emphasized the heterogeneous nature of nephrology care: nephrologists typically provide medical care in multiple settings with variations in patient population characteristics and health status and differential access to electronic health records (EHRs)—variations that may influence their ability to be successful in the MIPS program and should be considered by CMS.

The society recommended a number of modifications to CMS’ proposals based on these two factors of unique patient status and practice structure. In particular, ASN recommended that CMS require that reporting mechanisms include the ability to stratify the data by demographic characteristics such as race, ethnicity, and gender—and ASN urged CMS to use its resources in an active effort to continually improve the risk adjustment methodology employed within MACRA implementation. The need for appropriate quality measures that reflect the value of care nephrologists provide is also paramount.

Modify MIPS reporting requirements

In large part reflecting the unique patient and practice issues in nephrology, ASN also recommended a number of changes to the MIPS program. Specifically, the society promoted:

Reducing the number of patients on whom clinicians must report quality data to lower than that proposed by CMS in the “Quality” category.

Adjusting the “Resource Use” component of MIPS downward so that it makes up less of the total performance score; CMS proposed that Resource Use account for 10% of the total.

Increasing the number of proposed “Clinical Practice Improvement Activity” categories that qualify as “high value,” more accurately reflecting the effort clinicians put into improving their practices.

Implementing less stringent standards for use of EHRs (which CMS has branded “the Advancing Care Information” category of MIPS).

ASN collaborated with a number of other organizations in developing comments—including the American College of Physicians and the Council of Medical Subspecialty Societies—which echoed similar comments regarding making the MIPS program less onerous.

Create greater flexibility for APMs to form

APMs will provide new ways to pay health care providers for the care they give Medicare beneficiaries. APMs aim to deliver more coordinated, comprehensive care that focuses on population health and value, and they also take on an element of financial risk if the care that they deliver does not, in fact, provide good value. For the time being, every APM is a demonstration project currently being tested by the Centers for Medicare and Medicaid Innovation (CMMI). CMS proposed that clinicians who participate in APMs will get certain bonuses in the MIPS program—and ASN has urged the agency to give as much credit as possible to these clinicians, reflecting the challenges of practice transformation necessary to become an APM.

However, only clinicians who participate in Advanced APMs will be exempted from the MIPS program—and, these clinicians will receive a 5% bonus in the first few years of the Quality Payment Program. ASN is concerned that CMS proposed a very stringent definition of Advanced APMs, one that requires a significant amount of financial risk. Indeed, just six CMMI models currently being tested would meet the proposed financial risk criteria. As currently proposed, the substantial financial risk for losses for Advanced APMs will likely limit physician-driven participation and slow achievement of the goals of MACRA.

ASN believes the principle of comprehensive, integrated care inherent in APMs is a vitally important concept to advance to improve patients’ outcomes. The society urged CMS to create as many mechanisms as possible for interested physicians to establish and participate in APMs and Advanced APMs. In particular, the society encouraged CMS to consider alternate—still appropriately rigorous, but alternate—definitions of financial risk for “physician-focused payment models.” Physician-Focused Payment Models are an important aspect of MACRA that call for the creation of APMs centered on physician leadership—a concept that ASN strongly supports.

Set the stage for a comprehensive physician-led CKD model

At this time, CMS was not seeking recommendations for new APMs or Physician-Focused Payment Models. However, ASN indicated that it anticipates putting forward a “comprehensive CKD,” Physician-Focused Payment Model for consideration in the future.

A potential comprehensive CKD Physician-Focused Payment Model would put nephrologists at the helm of helping patients navigate the entire course of their advanced CKD. Encompassing all patients with advanced CKD, including kidney transplant recipients, such a model could focus on slowing the progression of kidney disease and other complex chronic conditions that are common in patients with advanced kidney disease. Inclusion of transplant patients for the duration of their lives within the scope of this model would create inherent incentives to promote transplantation for the greatest number of patients possible who are candidates, in addition to dialysis. Similarly, ASN envisions that a potential comprehensive CKD model would include palliative and/or conservative care options as those become appropriate considerations.

“I would like to commend the members of the Public Policy Board, led by John R. Sedor, MD, FASN, and by the ASN Quality Metrics Task Force, led by Daniel E. Weiner, MD, FASN, for their hard work in assessing and commenting on this proposed rule,” Harris said. Moving forward over the coming weeks and months, “ASN will be providing resources and insights to help our members understand how to prepare for and succeed in the Quality Payment Program, and will continue to engage with CMS to ensure a smooth transition going into 2019.”