Even without potential changes to the Medicare program, MACRA poses a significant challenge for any clinician trying to determine the best strategy to maximize Medicare reimbursement – there are hundreds of pages of guidance in the proposed and final regulations to review and understand. But, at this point, clinicians attempting to assess MACRA must also deal with uncertainty about changes to the Medicare program. A significant source of uncertainty is the Trump administration’s stated intent to repeal the Affordable Care Act (“ACA” and also known as Obamacare), which is being implemented by current legislative efforts. Uncertainty about the ACA should be considered in developing a strategy to comply with MACRA.

In assessing the MACRA uncertainty related to the ACA, the first thing to consider is that the ACA and MACRA are two, independent laws, so repeal of the ACA does not directly impact MACRA. Given the bipartisan support for MACRA (including the vote by Tom Price, the appointed Secretary of Health & Human Services), it seems unlikely that MACRA will be repealed or significantly altered.

Notwithstanding, repeal of the ACA may indirectly impact MACRA implementation by limiting potential advanced alternative payment models (“APMs”) available to clinicians. As covered in previous blog installments (Part 3 and Part 5), participation in an APM may provide benefits to a clinician in the form of increased reimbursement under MACRA and simplified reporting.

Most APMs, and in particular accountable care organizations (“ACOs”), are programs developed by the Medicare Innovation Center, which was created by the ACA. As a result, if the ACA were repealed without re-establishment of the Innovation Center or other payment model development authority through new legislation, the APMs established by the ACA, including ACOs, could potentially cease to exist. Elimination of ACA-based APMs would not necessarily mean there would be no APMs – new APM models could be introduced through the rule-making process – but uncertainty about the continuation of current APMs is likely to stymie further development of those models in the near future.

In summary, with respect to MACRA in the event of a repeal of the ACA, clinicians should be aware that:

  • even if the ACA is repealed, clinicians still face reimbursement adjustment (negative or positive) under MACRA – so clinicians should consider the best way to maximize benefit/minimize for 2019 (by acting in 2017 – see post Part 4); and
  • until the ACA is repealed, participation in an APM, such as an ACO, may provide benefits to a clinician under MACRA – but, given the uncertainty about the future of APMs if the ACA is repealed, significant investment in the development of an APM should be carefully considered pending further guidance about the future of APMs (e.g. it may not be worth starting an ACO from scratch, but it may be worth participating in an existing ACO).