House Energy and Commerce – Oversight and Investigations Subcommittee Hearing: “MACRA Checkup: Assessing Implementation and Challenges that Remain for Patients and Doctors”

On June 22, 2023, the Oversight and Investigations Subcommittee of the House Energy and Commerce Committee hosted a hearing entitled, “MARCA Checkup: Assessing Implementation and Challenges that Remain for Patients and Doctors.” The hearing featured several witnesses, including Joe Albanese, a Policy Analyst for Paragon Institute, Aisha Pittman, a Senior Vice President for the National Association of ACOs, Anas Daghestani, MD, Chair of the Board of America’s Physician Groups, CEO of Austin Regional Clinic, and J. Michael McWilliams MD, Ph.D., Professor of Health Policy and Medicine at Harvard Medical School.

Chair Morgan Griffith (R-VA) started the hearing by providing a historical context and framing the importance of MACRA, the Medicare Access and CHIP Reauthorization Act of 2015. He explained that MACRA was designed to facilitate the transition between physician reimbursement from a fee-for-service payment model to a value-based system that rewards high-quality care. Representative Griffith highlighted the importance of MACRA repealing the Sustainable Growth Rate (SGR). Subsequently, two new payment programs were created by the passage of MACRA through the Medicare Quality Payment Program (QPP) that created incentives for physicians to participate in value-based care over fee-for-service medicine. These two programs were: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The Congressman continued that the implementation of these two programs was costly and complex, but they are a well-intentioned attempt to prioritize value over volume. There are indeed several specific areas of concern, including the difficulty of QPP participation for providers in solo or small practices, rural areas, of underserved populations given the lack of capital and infrastructure required for entry. He attributed these barriers to the increasing trend of consolidation of healthcare and acknowledged the importance of being good stewards of Medicare funds and compensating doctors fairly to ensure access to care for all populations.

Urologists have particularly struggled with QPP participation given the lack of applicable measures that would be meaningful for patients who are being seen for urological issues. Furthermore, there are very few bundles that have been centered around urological specialty care. UroToday recently covered these programs, and other challenges relevant to urologists, in a video with Dr. Vishnukamal Golla: found here.

Next, the four witnesses were provided the opportunity to introduce themselves and their expert opinion on MARCA with opening statements that underscored the importance of shifting American healthcare from fee-for-service to a value and patient-centered system. All stressed that alternative payment models are indeed the future, but challenges remain in incentivizing practices to participate in these systems. Additionally, there was broad consensus from both the witnesses and Congressional representatives that the MIPS system is deeply flawed. Further, several mentioned that fully abandoning MIPS would be the best way to move forward. This is another pain point for urologists, as MIPS reporting rarely captures measures meaningful for urologists and urology patients. This was discussed with Dr. Avi Maganty, who has researched MIPS in urology, found here. Lastly, all witnesses called for reform in measures of quality, emphasizing the need for metrics that are meaningful and capture patient experience, care goals, and outcomes.

During the questioning portion of the hearing, several important areas of MACRA and Medicare were discussed. Many representatives were interested in hearing about the witnesses’ thoughts on how to boost APM participation. Solo practitioners, those who serve rural and underserved communities, and specialists all have unique challenges that serve as barriers to joining APMs. To address the infrastructure and financial barriers, suggestions regarding upfront payments to fund initial entry were made. Additionally, consistency and predictability of APM programs are essential to provide practice with reassurances regarding the stability and viability of their investments to join an APM – guaranteed 3, 5, or 7 year cycles were brought up as a suggestion to address this issue. Updates to data infrastructure were also brought up as potential improvements. Further, witnesses urged the Centers for Medicare and Medicaid services to engage specialty physicians to create bundles focused outside of the primary care space so that value can be emphasized more broadly. Leveraging existing specialty-specific outcomes databases were brought up as ways to encourage quality measurement and quality improvement activities.

Medicare Advantage (MA), which is actually not a Medicare program but rather a private Part C option for patients who are not enrolled in Original Medicare but only opt for Part A and Part B coverage, has further complicated the implementation of MACRA value programs. Recently, the issue of Medicare Advantage overpayments has emerged as a major area of concern. All agreed that expanding basic Medicare is the key to making traditional Medicare a more viable competitor and reducing excess MA spending.
Overall, all subcommittee members stressed that since the annual APM incentive is set to sunset at the end of 2023, they plan to introduce significant improvements to MACRA’s QPP to help strengthen the shift towards true, patient-centered value within the healthcare system.

Written by: Ruchika Talwar, MD, Urologic Oncology Fellow, Vanderbilt University Medical Center, Nashville, TN