The mention of MACRA leaves fear in the hearts of many people in the healthcare organization for one or all of the following reasons.

The pressure from the MACRA regulatory bodies are significant and increasing by the day. Per a 2016 Health Catalyst/Peer 60 survey, health systems’ top MACRA concern is compiling metrics for regulatory reporting. There are many regulatory pressures on health systems that come from multiple sources: regulatory agencies, Meaningful Use, increasing costs, the need to improve safety and quality, risk contracts, etc.

In addition, the processing of quality measures is a major source of physician dissatisfaction. The average physician spends 15.1 hours a week processing quality metrics (Weill Cornell Medical College and Medical Group Management Association), which translates to $40,069 per physician, per year. MACRA requirements are likely to have increased this workload. 15 hours is already a huge chunk of the physicians dedicated to paperwork. An increase in this will take a huge chunk away from the physicians and further deter physician engagement.

The penalties associated with regulatory noncompliance are very high. Under the Mips and Apms track of MACRA, payments start at plus or minus 4 percent in 2019 and incrementally increase to plus or minus 9 percent in 2023. This puts a huge dent in an already less than par physician revenue.

The lack of coordination between different departments such as financial, regulatory, quality etc is a cause for worry. Significant human resources and manual processes are needed to assemble regulatory measures, which are difficult to compile, interpret, maintain, and understand.

Insufficient information and knowledge on Mips and Apms. There are so many facets to MACRA, so many terminologies that need to be learned, so many rules to follow. It is quite the nightmare. Healthcare practitioners need to understand what Mips and Apms mean. MIPS is essentially a streamlined program that is based on existing programs. These include the Physician Quality Reporting System, the Medicare Electronic Health Record Incentive Program, and the Value-Based Payment Modifier. These programs are all now grouped under the title Quality Payment Program.

The primary difference between MIPS and APMs is that choosing APMs exposes providers to greater financial risks, but it also has the potential to deliver greater financial rewards. There are financial incentives applicable under APMs related to the level of financial risk undertaken by the provider and the quality of care provided.

Providers’ performance will be measured under four categories, namely quality, costs, the use of certified EHR and improvements in clinical practice. Each category is weighted, and providers will receive a score of between 0 and 100. This score will then be used to adjust payments. For 2017, the quality component is weighted at 60 percent, cost at 0 percent, use of EHR at 25 percent and clinical practice improvements at 15 percent. The latter two categories will remain at those percentages until 2019. Quality will reduce to 50 percent in 2018 and 30 percent in 2019, while the cost category will increase to 10 percent in 2018 and 30 percent in 2019.

APMs which stands for the Advanced Alternative Payment Models program includes some demonstration programs, ACOs, the Medicare Shared Savings Program and the initiatives introduced by the Centers for Medicare and Medicaid Services Innovation Center, with the exception of the Health Care Innovation awards.

Providers who want to be paid using APMs will be bound by law to accept financial risk. Furthermore, they will need to be able to show that they can deliver better quality without additional cost, or that they can reduce costs without adversely affecting quality. Providers will also need to show that a large portion of revenue comes from an APM.

While the difference between MIPS and APMs is clear, it is noteworthy that the quality measures applied by providers using an APM are similar to the ones used under MIPS. Providers using APMs must, like those using MIPS, implement the use of EHR technology.