Earlier this summer, the House Energy and Commerce Committee held a hearing entitled, “MACRA Checkup: Assessing Implementation and Challenges that Remain for Patients and Doctors.” The hearing reviewed the successes and remaining challenges of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The hearing explored the administrative burden of the Merit-based Incentive Payment System (MIPS), the transition to Alternative Payment Models (APMs), and the impact on small independent doctors as well as those in rural and underserved areas.
In announcing the hearing, Energy and Commerce Committee Chair Cathy McMorris Rodgers and Subcommittee on Oversight and Investigations Chair Morgan Griffith released a joint statement, saying, “It’s crucial that we continue to improve our health care system in a way that best serves patients and doctors. The bipartisan Medicare Access and CHIP Reauthorization Act (MACRA), which extended the critical Children’s Health Insurance Program, also intended to create incentives in Medicare to provide seniors with better quality care rather than just greater volume of care. Additionally, the law sought to more effectively use taxpayer dollars and make Medicare more sustainable. This hearing will give members an opportunity to hear from experts, evaluate the implementation of the law, and better understand what challenges remain.”
Witnesses present to testify at the hearing included Joe Albanese, a policy analyst at Paragon Institute; Aisha Pittman, Senior Vice President at the National Association of ACOs; Anas Daghestani, MD, Chair of the Board of America’s Physician Groups and CEO of the Austin Regional Clinic in Texas; and J. Michael McWilliams, MD, PhD, Warren Alpert Foundation Professor of Health Care Policy Professor of Medicine Department of Health Care Policy at Harvard Medical School.
Opening Statements
Chair McMorris Rodgers highlighted the “bipartisan solutions to enhance transparency and reduce health care costs,” including a bipartisan health package that was recently moved through the full committee unanimously. McMorris Rodgers also praised MACRA for “a new approach that prioritizes quality over quantity,” but noted that there was still more work to be done as “more Americans age into the Medicare program and the financial and regulatory pressures on health care providers inside and outside of Medicare mount.”
Ranking Member Frank Pallone, Jr., noted that while MACRA and MIPS have tried to “provide better pay for health care providers who provided better care,” “this system has appeared to create additional administrative burdens for providers without producing significant improvements in patient care.”
Subcommittee Chair Griffith noted that “MACRA charted a new course for Medicare and attempted to put it on a more sustainable financial course,” but that it has also led to “additional levels of administrative complexity and costs,” which has “slowed down the adoption of MACRA’s quality payment programs.”
Subcommittee Ranking Member Kathy Castor noted that “both payment models [MIPS and APMs] have failed to meet their intended goals” and that “this is an appropriate time to assess how the reforms have lived up to the original legislative goals and what we can learn from the experiences of doctors and patients in our communities.”
Witness Testimony and Discussion
Joe Albanese discussed the way that MACRA has helped to slow the clinician payment growth, sustainability is in question since Congress has already made changes and overridden payment updates in years past. He also referenced the “significant impact” that certain MACRA provisions have had on doctors’ finances due to compliance costs and performance initiatives – particularly small providers. He recognized that “placing more requirements on doctors may be worth the additional costs if it encourages them to adopt necessary improvements that will benefit patients in the long run” but that the financial incentives in MACRA “may not have had their intended effect.”
Aisha Pittman focused on the way ACOs have successfully implemented value-based care transformation as compared to the fee-for-service system – to the tune of generating more than $17 billion in savings with $6.4 billion being returned to the Medicare Trust Fund over the last decade, all while maintaining high quality scores for their patients. Pittman discussed the way APMs have “produced a ‘spill over’ effect on care delivery across the nation, slowing the overall rate of growth of health care spending.” However, Pittman also noted that MACRA implementation has come with challenges, including incentives favoring MIPS and limited payment models for providers.
Anas Daghestani, MD, spoke to the improvements MACRA has made to Medicare since 2015, while also noting some aspects of the law that have not lived up to their potential and the “substantial opportunities” that exist to “reengineer the law to improve the care of millions of Medicare beneficiaries and obtain far better value for the dollars expended on health care for both beneficiaries and American taxpayers.” Daghestani noted that physician payment under Medicare has fallen more than 25% from 2001 to 2023, when adjusted for inflation. Daghestani suggested “ensuring that all enrollees in the traditional Medicare program – as well as most Medicaid enrollees – are in ‘longitudinal, accountable [relationships] with providers that are responsible for the quality and total cost of their care.’”
Michael McWilliams, MD, PhD, made several points during his testimony, including that APMs are promising and worth encouraging and that the APM bonus should be extended and restructured for greater effectiveness. McWilliams also noted that “other strategies to support high-quality care should be prioritized,” including “building better data systems to support providers and promoting competition.” McWilliams also stated that any discussions surrounding Medicare reform would need to consider the implications of the rapid growth of the Medicare Advantage program, as if “MA grows, and if APMs resume their growth, the MIPS will soon become obsolete and unworkable as the residual population becomes too small to support it,” and therefore, “any discussion of the value and future of APMs begs for a discussion of the value and future of the Traditional Medicare program, particularly its role as a public option in facilitating regulation of MA and strengthening the Medicare program as a whole.”