A recent article in the New England Journal of Medicine describes the evolving reimbursement changes mandated by Medicare as a “coming battle” between primary care physicians and specialists.1 There has been very little to date in the critical care literature about these changes or how they might affect intensivists. In this article, we provide an overview of the legislative changes to Medicare, how they may affect physician reimbursement, and specifically how they might affect intensivists. It will be up to the critical care community to determine appropriate responses to this changing environment.
Beginning in 2012, the Centers for Medicare and
Medicaid Services (CMS) began implementing new and
innovative payment methods mandated in the Patient
Protection and Affordable Care Act. Accountable care
organizations (ACOs) and patient-centered medical
homes were first, followed by various bundled payment
programs. To qualify as an ACO, an organization
must agree to be accountable for the overall care of its
Medicare beneficiaries through primary care providers,
emphasize and support evidence-based medicine, report
on quality and costs, and utilize care coordination. These
organizations are reimbursed through both public and
private programs and can be organized by either hospitals
or provider groups. They generally have a primary care
provider and a preventative and chronic disease-based
approach to managing care and capitated risk for a
CMS recognizes that the emphasis on primary care
and population health management is a necessary but
insufficient approach to addressing rising healthcare
costs while improving healthcare quality. Primary
care providers account for only 6% of healthcare
expenditures, while specialists outnumber primary
care providers in the United States by 26%.2
Medicare patient sees five specialists and three primary
care providers in four different practices each year.3
Bundled payment programs, including the voluntary
Bundled Payments for Care Improvement initiative
and the mandatory Comprehensive Care for Joint
Replacement model, have helped CMS move 30% of
Medicare payments away from traditional fee-for-service
with a goal of 50% by 2018.4
Bundled payment programs
are attractive to providers who are very good at one or
a few procedures and who care for otherwise healthy
patients, since to date there is no risk adjustment used
in the reimbursement methodologies. However, for that
same reason, these programs are limited as methodologies
that could be extended to all of Medicare.
What Is MACRA?
In April 2015, President Obama signed the Medicare
Access and CHIP Reauthorization Act (MACRA),
which repealed the Sustainable Growth Rate (SGR)
mechanism for Medicare physician reimbursement
and mandated that CMS develop alternative payment
methodologies to “reward health care providers for giving
better care, not just more care.”5
MACRA makes three major changes to Medicare reimbursements: (1) it ends
the SGR formula, (2) it establishes a new framework to
reward physicians based on performance and health
outcomes rather than volume, and (3) it aims to combine
existing quality reporting programs into one streamlined
system. MACRA establishes an annual physician fee
schedule update of 0.5% from 2016 to 2019. After that,
the Medicare physician fee schedule will remain at 2019
levels through 2025. Beginning in 2019, physicians must
enter one of two new tracks for payment: the MeritBased
Incentive Payment System (MIPS) or Alternative
Payment Models (APMs).6
What Are MIPS and APMs?
CMS is developing MIPS as traditional fee-for-service
Medicare with improved-quality metrics and streamlined
reporting requirements. The maximum MIPS payment
adjustment will be 9% +/-. MIPS will subsume the
Physician Quality Reporting System, the Value-Based
Payment Modifier and the Medicare Electronic Health
Record Incentive Program for eligible providers.
However, CMS wants to continue to move providers
into greater than nominal risk-bearing arrangements.
To that end they are also developing APMs in which
providers can earn higher rewards for better care, but
also have greater risk of financial loss if care costs exceed
expectations. Payment adjustments for participants
in qualifying APMs will include both a 5% incentive
payment plus any shared savings achieved by the
APM—with potential payment adjustments available
through APMs far exceeding those available through
MIPS. Under MIPS, physicians can expect, based upon
the fee schedules defined in the MACRA legislation, a progressive reduction in reimbursement even if all quality
metrics are met. Incentives in the APM program provide
the possibility of increasing physician reimbursement over
the first five years of the program.
Neither MIPS nor APMs are completely defined, let
alone implemented; over the next five years, CMS will
be developing the final structures and policies for these
payment methodologies. Some experts have already
voiced significant concern that these innovative payment
and delivery models may not be the keys to cost control
and quality improvement.7
Provider groups can propose
Physician-Focused APMs to an independent PhysicianFocused
Payment Model Technical Advisory Committee
that will review them and make recommendations to
CMS on whether or not to adopt them.
The “Advanced APMs” under development in this
arena comprise much more complex and comprehensive
plans that include coverage for acute and chronic
conditions, sophisticated risk adjustment, advanced
tools to measure quality and resource use, and methods
to assign risk and rewards to large panels of providers.
These APMs will likely use both administrative and
clinical data, will analyze both acute and chronic episodes
of care, and consequently will include a much broader
array of providers than bundled payment plans. Provider
organizations and specialty societies are actively working
to develop APM models to present to CMS. Despite CMS
being the prime mover in this work, private payers will be
expected to follow Medicare’s lead, and all-payer APMs
will follow. Ongoing improvements in both electronic
health records and billing and coding methodologies will
make that development even more likely.
How Do MACRA, MIPS and APMs Impact Critical Care
For CMS, the intent is not just to eliminate waste and
unnecessary care, but to provide incentives to providers
and organizations for care redesign. The allocation
of care, and thus reimbursement, between primary
care providers and specialists will depend upon the
new and innovative organizational structures that
arise in this effort, and on how both primary care
providers and specialists can demonstrate their value
to the organization. Intensivists, in functioning as both
specialists and primary care providers for their patients in
the intensive care unit (ICU), have a unique professional
role that will need to be defined clearly and appropriately
in new reimbursement methodologies.8
With the passage of MACRA, there is now an
opportunity to have physician and society input into the
development of the APMs and quality measures that are
relevant to critical care and specific patient populations
in our ICUs. The development of MIPS performance
measures specific to critical care would be an excellent
advance within this new framework. The changing
incentives contained within the MACRA legislation will
spur both reimbursement redesign and care redesign
that will affect all providers. That redesign will influence
provider roles and provider relationships.
The ICU is the locus of high-cost healthcare in
this country—the place where care quality and care
coordination are paramount, both for improving
outcomes and controlling costs. Intensivists are best
positioned to inform the development of appropriate
quality measures to accurately and comprehensively
evaluate critical care services in the ICU. Furthermore,
intensivists work at the place where the coming
integration of hospital and provider reimbursement will
have the largest impact. The reimbursement changes
outlined here will likely have a significant effect on
intensivists and how we care for our patients—and how we interact with our colleagues and are paid for those
interactions. Determination of appropriate physician
reimbursement for critical care services will be important
in MIPS and especially in the APMs.
The devil will be in determining the details. What
is the scope of an APM model? Which providers are
included within the model? Will the model cover acute
episodes of care (an advanced bundled care model,
perhaps with some risk adjustment) and will it also cover
the management of chronic medical problems? How
will financial responsibility for a patient be distributed
among the various providers of care? How is quality
of care assessed in the APM model? What metrics will
be used for the patient who spends a period of time in
a surgical ICU after surgery or in a medical ICU for
an acute exacerbation of a chronic medical problem?
How are these metrics translated into reimbursement
rewards and penalties in the reimbursement algorithm?
Will compliance with ICU staffing standards necessary to
provide a minimum standard of care and patient safety in
an ICU be part of the CMS quality algorithm?9,10
The Society of Critical Care Medicine is
dedicated to educating the critical care community
about reimbursement policies. Several professional
organizations have provided statements regarding
MACRA, some particularly focused on the development
of APMs.11,12,13,14 Appropriate reimbursement models
could help pave the way for more robust and uniform
standards in critical care medicine education and
credentialing,15 and could even influence federal funding
for critical care education. The critical care community
has a unique opportunity to be part of the discussion
around developing new physician payment models
specifically for critical care services.
1. Kocher R, Chigurupati A. The coming battle over shared savings—primary care physicians versus specialists. N Engl J Med. 2016 Jul 14;375(2):104-106.
2. Hing E, Schappert SM. Generalist and specialty physicians: supply and access, 2009-2010. NCHS Data Brief. 2012 Sep;(105):1-8.
3. Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med. 2007 Mar 15;356(11):1130-1139.
4. Mechanic RE. When new Medicare payment systems collide. N Engl J Med. 2016 May 5;374(18):1706-1709.
5. H.R. 2 (114th): Medicare Access and CHIP Reauthorization Act of 2015.
6. Rappleye, E. MACRA Roadmap: 9 questions on a post-SGR world, answered. Becker’s Hospital CFO. April 21, 2016. . Accessed February 13, 2017.
7. Oberlander J, Laugesen MJ. Leap of faith—Medicare’s new physician payment system. N Engl J Med. 2015 Sep 24;373(13):1185-1187.
8. Popovich MJ, Esfandiari S, Boutros A. A new ICU paradigm: intensivists as primary critical care physicians. Cleve Clin J Med. 2011 Oct;78(10):697-700.
9. Ewart GW, Marcus L, Gaba MM, Bradner RH, Medina JL, Chandler EB. The critical care medicine crisis: a call for federal action: a white paper from the critical care professional societies. Chest. 2004 Apr;125(4):1518-1521.
10. Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest. 2009 Apr;135(4):1038-1044.
12. Nickels T. Statement on MACRA proposed rule. Chicago, IL: American Hospital Association. April 27, 2016. http://www.aha.org/presscenter/pressrel/2016/160427-pr-macra.shtml. Accessed February 13, 2017.
13. American Hospital Association. Statement of the American Hospital Association before the Subcommittee on Health of the Committee on Ways and Means of the U.S. House of Representatives. Chicago, IL: American Hospital Association. May 11, 2016. http://www.aha.org/advocacy-issues/testimony/2016/160511-tes-macra.pdf. Accessed February 13, 2017.
14. Alliance of Specialty Medicine. Statement of the Alliance of Specialty Medicine on MACRA Implementation before the Subcommittee on Health of the Committee on Energy and Commerce of the U.S. House of Representatives. Washington, DC: Alliance of Specialty Medicine. April 19, 2016. https://www.aans.org/pdf/Legislative/Alliance%20of%20Specialty%20Medicine%20MACRA%20statement%20for%20April%2019%202016%20House%20EC%20hearing.pdf. Accessed February 13, 2017.
15. Kaplan LJ, Shaw AD. Standards for education and credentialing in critical care medicine. JAMA. 2011 Jan 19;305(3):296-297.