MACRA Changes Health Care Economics with a Focus on Children
MACRA Background: A final rule released on Oct. 14, 2016 by the Centers for Medicare and Medicaid Services (CMS) details the final regulations for implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the historic Medicare reform law that repealed the Sustainable Growth Rate (SGR) formula last year.
CHIP Background: In 2009, the Children’s Health Insurance Reauthorization Act (CHIPRA) was signed into law, extending and reauthorizing the Children Health Insurance Program (CHIP) legislation and setting forth additional funding and options to expand health care and improve health coverage for eligible children through Medicaid and CHIP. CHIP is targeted primarily at the Medicaid population. The Affordable Care ACT (ACA) expanded Medicaid to 138% of the Federal Poverty Level (FPL) for Household Income. Studying this more deeply, one can see that children have improved access to care in households with income up to 350% percent of the population unless there is a pregnant woman in the home, which then increases the threshold to 400% of FPL. Disabled child populations are also a key focus area of CHIP and Medicaid.
MACRA impacts Medicare payments because it stops reductions in physician payments, switches the framework for quality measurements and it merges prior initiatives together:
- Repeals the Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians.
- Creates a new framework for rewarding physicians for providing higher quality care by establishing two tracks for payment:
- Merit-based Incentive Payment System (MIPS), and
- Alternative Payment Models (APMs)
- Combines three quality reporting programs (Physician Quality Reporting System, Value-based Payment Modifier, and meaningful use of electronic health records.
Healthcare Economic Stimulus Package
One state Assemblyman from Utah who is also a physician believes that improved access to care is the greatest economic stimulus package of all. When families know their children are healthy they are more able to focus on being productive members of society. For every $1 of funds put into the health care system, he argues, $9 of increases to the economy result in terms of tax paying health care workers and patients who are healthier and more able to work.
Where do we see the most potential impact on reducing the cost of care? According to the Centers for Disease Control, “Chronic diseases are responsible for 7 of 10 deaths each year, and treating people with chronic diseases accounts for 86% of our nation’s health care costs. CDC’s chronic disease prevention system brings together data, health care systems, and communities to support healthy choices and reduce risk behaviors for all Americans.”
Epidemiology and surveillance—to monitor trends and track progress.
Environmental approaches—to promote health and support healthy
Health care system interventions—to improve the effective delivery and
use of clinical and other high-value preventive services.
Community programs linked to clinical services—to improve and
sustain management of chronic conditions.
Affordable Access to Care and Ambulatory Care Sensitive Conditions
Access to affordable care is key, and the Affordable Care Act’s Medicaid Expansion improves this access for millions of Americans. What we do with improved access to operationalize CDC’s pillars is the challenge. In the U.S. and other countries, studies have found a strong correlation between access to primary care and Ambulatory Care Sensitive Conditions (ACSC).
For example, a 2009 study of ACSC in Italy compared factors there to the U.S. the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for :
1. chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and
2. congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.
Therefore, CMS proposes shifting the focus on quality to Ambulatory Care Sensitive Conditions and associated readmissions.
Developmentally Disabled Children and ACSCs
Delivering Results Requires Education and Interoperability
Affordable Access and measurement of outcomes will only work to reduce cost if treating clinicians have access to relevant clinical data. In our opinion, the largest investment and opportunities will come not from access, but health data integration and interoperability while ensuring HIPAA and HITECH Act privacy and security. Medicaid disabled children and their families will need continuing and substantial education about access to care opportunities to enable the health care system to execute on early interventions to reduce costly chronic disease treatments later in life.
CONCLUSION : in MACRA, “A” is for Access and “C” is for Children
Remember that the intent of MACRA encompasses earlier interventions starting with improved Access to care for Children. It emphasizes the importance of the Children’s Health Insurance Program, or CHIP. CHIP is focused on those children and families earning less than 350% of the Federal Poverty Level. Children’s Hospitals across the U.S. and retail clinics that serve families have a unique opportunity ahead.