Mad About MACRA

Margaret Tempero
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Well, we survived the first month of the implementation of MACRA and we're still here to talk about it. To be completely transparent, I confess I have known about this reform in only the broadest of terms, so I had to do a bit of homework before I could opine about it intelligently.

MACRA's full name is “Medicare Access and CHIP Reauthorization Act.” Now, I'm not even sure what all that means, but it is always accompanied by a comment about how this will transform Medicare reimbursement and care delivery in America. Wow! That sounds like a good thing!

I haven't gotten to the point of complete understanding of how this will all work in full implementation, but we're supposed to be receiving a score and payment adjustments (which includes possible penalties, by the way) on quality, cost, improvement, and advancing care information. Advancing care information replaces “meaningful use,” so we can forget about that earlier experiment now. By the way, does anyone know if “meaningful use” was ever very useful?

Moving forward, CMS has asked us to test the waters slowly, so we really only have to report one quality measure in 2017. But since more changes will be implemented in 2018, organizations like ASCO have suggested reporting on at least 4. CMS has a variety of mechanisms for reporting quality metrics that it will accept; however, reporting is currently manual only, so a cost must be associated with this for practices. Admittedly, a plan is forming to integrate reporting with the electronic health record, but that integration is a ways off.

How we will incorporate cost and the other variables into this new formula is still a mystery to me, but I'm trying to learn. It strikes me, though, that this is yet another CMS “experiment”—designed with good intentions, as always, but likely full of unintended consequences.

As you might expect, I chose the title for this editoriual with tongue in cheek. Being “mad” about something could be interpreted as passionate or angry. In truth, I am passionate about reimbursement reform, such as bundled payments; comprehensive codes to cover episodes of care, such as chemotherapy and supportive care; or simply just better payments for E and M codes. Regarding the latter, it still frosts me that spending 30 minutes talking a patient out of having an expensive procedure they do not need brings in only enough to cover office expense.

So I'll try to keep an open mind about MACRA. After all, we all want to see high-quality, cost-effective cancer care in every practice. But I worry that this will financially squeeze practices to the breaking point and create more difficulties with access to care.

I truly believe we need a different kind of comprehensive reform from CMS. One that reduces administrative costs for practices and addresses the cost of drugs, among other things. I'm not suggesting it's easy, but it can't be any more complicated than MACRA!

What do you think? Please e-mail correspondence (include contact information) to or log into to submit a Letter to the Editor.

Margaret Tempero, MD, is a Professor of Medicine and Director of the UCSF Pancreas Center and editor-in-chief of JNCCN. Her research career has focused on pancreatic ductal adenocarcinoma, especially in the area of investigational therapeutics. Dr. Tempero has served on the ASCO Board of Directors and as ASCO President. She currently serves on the ASCO Conquer Cancer Foundation Board. She codirected the AACR/ASCO Methods in Clinical Cancer Research and taught this course and similar courses in Europe and Australia. She was founding Chair of the NCI Clinical Oncology Study Section and served as a member and Chair of the NCI Board of Scientific Counselors Subcommittee A. She is a member of the Scientific Steering Committee and Chair of the Clinical and Translational Study Section for the Cancer Prevention & Research Institute of Texas. She is or has been on the Scientific Advisory Boards of the Lustgarten Foundation, the Pancreatic Cancer Action Network, the V Foundation, The Alberta Canada Cancer Board, and the EORTC. She served as a member of the Oncology Drug Advisory Committee for the FDA. She has served as Deputy Director and Interim Director for the UNMC Eppley Cancer Center. She is Chief Emeritus of the Division of Medical Oncology at UCSF and served as the founding Deputy Director and Director of Research Programs at the UCSF Helen Diller Family Comprehensive Cancer Center.

The ideas and viewpoints expressed in this editorial are those of the author and do not necessarily represent any policy, position, or program of NCCN.

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