The Future of Health Care - The Medicare Access and Chip Reauthorization Act (MACRA)

By David Provenzano, MD, and Alexandru Visan, MD, MBA    Nov 22, 2016

David Provenzano, MD

In April 2016, the Centers for Medicare and Medicaid Services (CMS) published the proposed rule implementing the Medicare Access and Chip Reauthorization Act (MACRA) of 2015. MACRA is not a stand-alone act as it builds on years of transformative health care legislative efforts including the Tax Relief and Health Care Act of 2006 (which established the physician quality reporting systems PQRS); the Medicare Improvements for Patients and Provider Act of 2008 (MIPPA); the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, which is part of the American Recovery and Reinvestment Act (which established incentive payments to eligible professionals to promote the adoption and meaningful use of certified electronic health record technology); and the Affordable Care Act of 2010 (which established the value-based payment modifier). At the same time, MACRA received significant bipartisan support within both chambers of U.S. Congress and the White House. As such, this

does represent a strong signal of bipartisan support from the executive and legislative branches of the U.S. government for a transition toward value-based payments within the health care system.

Implementation of MACRA will have a significant impact on the future direction and structure of health care regardless of practice type (i.e., academics, hospital based, and private practice). The new legislation will replace the sustainable growth rate (SGR) formula with goals of paying health care providers based on the value and quality of care provided to covered participants. Under MACRA, two new payment systems will coexist: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). These new reimbursement platforms will significantly affect health care delivery and reimbursement. In addition, implementation of MACRA will result in major challenges for physicians as they integrate into these new payment models and program requirements.

ASRA, recognizing the challenges that society members are facing, developed a special task force to assist in educating members and to appropriately provide comments to CMS as new legislation is being developed. The task force, which was developed under the direction of ASRA president Dr. Oscar De Leon-Casasola, consists of both regional anesthesia/acute pain medicine and chronic pain medicine teams. The two-team model was created based on the understanding that each sector of pain management may face different challenges under the new legislation. Chronic pain members are Drs. David Provenzano, Carlos Pino, and Kevin Vorenkamp. Regional anesthesia/acute pain members are Drs. Alexandru Visan, Arthur Atchabahian, Douglas Jaffe, and Sanjay Sinha. The Executive Director of ASRA (Angie Stengel, MS, CAE) has also been instrumental in ASRA’s ability to respond to MACRA.

Throughout the months of May and June, ASRA worked with six other organizations (American Academy of Pain Medicine [AAPM], American Academy of Physical Medicine and Rehabilitation [AAPMR], American Society of Anesthesiologists [ASA], American Society of Interventional Pain Physicians [ASIPP], North American Neuromodulation Society [NANS], and Spine Intervention Society [SIS]) to provide comments to CMS. In the letter, 11 specific points were outlined for CMS.

Chronic Pain Management and MACRA

Under the quality payment program, a majority of chronic pain physicians will participate in MIPS unless they are part of an organization that has a well-developed advanced APM that is approved by CMS. The MIPS program is budget neutral and will score physicians in four performance categories (Table 1): 1) cost, 2) quality, 3) clinical practice improvement activities, and 4) advancing care information. The program will provide adjustments to fee-for-service payments that range from ± 4% in 2019 (reflecting 2017 reporting year data) to ± 9% in 2022 and beyond. The calculated composite MIPS score will be used to compute a positive or negative or neutral adjustment to a health care provider’s Medicare payments. Participation in an APM (Table 2) exempts a provider from the MIPS payment program and allows the health care provider to qualify for a 5% Medicare part B incentive payment from 2009-2014.

Of  the 11 points made to CMS by the multisociety letter, areas specific to chronic pain management include: MIPS low-volume threshold and participation by solo practitioners and small group practices, advanced APMs, MIPS quality performance measurement, MIPS resource use measurement, facility-based MIPS eligible clinicians and group, MIPS advancing care information (ACI) measurement, MIPS clinical practice improvement activities (CPIA) measurement, and MIPS Composite Performance Score (CPS) reweighting. Please refer to the multisociety letter for further detail on recommendations. The letter comments directly on CMS’s proposed rule to implement MACRA. CMS will take recommendations from ASRA and other stakeholders into consideration when writing the final rule expected for release around November 1, 2016.

CMS will continue to release multiple rules in future years related to MACRA and as implementation policy issues arise when the program becomes effective. In August, ASRA responded to the physician-patient relationship categories and code guidance, which will inform CMS in its development of episode and patient condition groups for which physicians could be measured for purposes of meeting MACRA requirements.

Acute Pain Management and Regional Anesthesia and MACRA

While we urge you to read the multisociety comment letter, we would like to bring to your attention some essential comments that our group provided to CMS for consideration.

  1. We strongly urge and request that CMS establish an interim, shortened process for developing subspecialty-specific measure sets until CMS formally adopts subspecialty-specific quality measures.
  2. MACRA implementation, in its current form, will have a significant impact on individual and small practices, from a regulatory and financial perspective.
  3. There is limited opportunity for specialists in our field to participate in APMs. In current form, it is estimated that a majority of our specialty members will participate in MIPS. Given the current definitions, they will also be considered non-patient facing clinicians. That creates a degree of complexity regarding reporting and reweighting of various components within the reporting system.
  4. The societies support considering the Comprehensive Care for Joint Replacement (CCJR) as an Advanced APM. At the time of this letter, CMS is requesting comments on a separate proposal that would consider CCJR an Advanced APM. The date and many details of the implementation phase are under review by CMS.


In conclusion, MACRA is just one of the many current regulatory efforts that create a very dynamic and challenging health care environment. New payment models proposed through MACRA will have significant consequences for all health care providers. ASRA will continue to work both independently and with the other societies to provide substantive recommendations to CMS. Education will be provided continuously on MACRA through our educational meetings. We recommended that all members involved in chronic pain management check out the educational opportunities offered at 2016 Fall Pain Meeting in San Diego. In addition, the 2017 Spring Acute Pain meeting in San Francisco includes a specific Practice Management Portfolio where you will be able to find answers to many of the health care challenges, including the current regulatory environment. Furthermore, if you have specific concerns regarding MACRA please email us at


David Provenzano, MD, is cochair of the ASRA MACRA Task Force and president of Pain Diagnostics and Interventional Care in Pittsburgh, PA, and Alexandru Visan, MD, MBA, is cochair of the ASRA MACRA Task Force, CEO of Executive Cortex Consulting, and Voluntary Assistant Professor of Clinical Anesthesiology at the University of Miami in Miami, FL.

Note: This article originally appeared in the ASRA News, Volume 16, Issue 4, pp. 7-8 (November 2016).

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