The Journey to Value-Based Payment Continues

Dr Paul CasaleThis post was authored by Paul Casale, MD, MPH, FACC, a member of ACC’s Board of Trustees and chair of the Partners in Quality Subcommittee.

Health care is undergoing a transformation in regard to how we, as physicians, are paid for our services. Over the last decade, the Medicare Prescription Drug, Improvement and Modernization Act, the Deficit Reduction Act of 2005, the Tax Relief and Health Care Act of 2006, the Patient Protection and Affordable Care Act of 2008, and the American Recovery and Reinvestment Act of 2009 have gradually moved the needle on quality reporting. While we’ve been on the journey from fee-for-service to pay-for-value for years, 2015 was a pivotal year for the transition to value-based payment.

Last year introduced the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), legislation that permanently repeals the Sustainable Growth Rate, establishes a framework for rewarding clinicians for value over volume and streamlines quality reporting programs into one system. MACRA also established two new payment pathways for clinicians that will start in 2019: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Starting in 2019, the MIPS will be the new performance-based payment program for eligible professionals in fee-for-service Medicare. The new payment system under MACRA reflects the commitment by Congress to reward value over volume and streamline programs to make it easier for clinicians to participate. As such, MIPS combines the three existing quality reporting programs – Meaningful Use, the Physician Quality Reporting System and the Value-Based Modifier – into one program where the value-modifier payment adjustment will be informed by four domains:  meaningful use of electronic health record technology, clinical practice improvement, quality and resource use.

U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell’s announcement that the agency will begin tying Medicare reimbursement to APMs (30 percent by 2016 and 50 percent by 2018) was a big step forward for moving from volume- to value-based payment. As a member of the new Physician-Focused Payment Model Technical Advisory Committee, created under MACRA, I look forward to providing information and recommendations on physician payment models to the HHS secretary.

Additionally, CMS, through the Center for Medicare and Medicaid Innovation, has a number of pilot programs already operational ranging from various Accountable Care Organization (ACO) models (Shared Savings, Pioneer and Next Generation) to the Bundled Payment for Care Improvement initiative. Of note, almost 17 percent of cardiologists participated in a Medicare ACO in 2013. There is also momentum to apply some of the pilot payment models for national implementation based on cost savings alone or combined with improvements in quality. A complementary effort is underway for the private sector through the Health Care Transformation Task Force, whose membership includes payers, providers, purchasers and patient groups, to have 75 percent of payments by 2020 tied to value (i.e., incentivize and hold providers accountable for total cost, patient experience and quality of care for population of patients).

Because payment reforms mandated by MACRA create higher-stakes around performance measurement and alternative payment activity, the Partners in Quality Subcommittee of the College’s Advocacy Steering and Clinical Quality Committees brought together ACC member leaders in measure development, implementation and/or advocacy for a Strategic Roundtable on Measuring and Paying for Value in Cardiovascular Care last year.

While the value-based payment landscape continues to evolve rapidly, the time is right to determine how ACC can more efficiently and effectively contribute to meet cardiologists’ needs as new payment models are implemented.

 Stay tuned to for monthly articles on value-based payment to help you navigate the changing landscape. Get a complete summary of “Measuring and Paying for Value in Cardiovascular Care: Past, Present and Future” and read about “Ensuring Value in a Value-Based Health System” and “A Micro View of MACRA” in recent Leadership Pages published in the Journal of the American College of Cardiology. The 2016 Cardiovascular Summit: Solutions for Thriving in a Time of Change, Feb. 18 – 20 in Las Vegas, NV, will provide an important forum for continued discussions on MACRA and new payment models. Register on

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