Anticipating MACRA and Medicare Advantage impacts

MACRA continues to evolve and while its impacts may have been somewhat softened over the last several months, MACRA’s intent is still to have an impact on care costs and quality over short and long term. While many providers are concerned and strategizing about the financial and administrative implications of MACRA, payers should also consider exploring and anticipating MACRA impacts.

There are some early indications, for example, that Medicare Advantage (MA) plans may be impacted by provider reactions to MACRA. Many providers across the country recognize that if they reduce the number of their Fee For Service (FFS) patients to less than 200 or $90k in annual charges they can avoid MACRA and MIPS exposure altogether. In many counties, provider’s reactions to MACRA may cause an increase in MA membership.


Learn more at Viewpoints on the 2019 CMS Call Letter

While more patients moving to MA plans can help MA plans to increase membership growth; this migration can also introduce unknown impacts to actual plan claims and throw off MA plan projections. Medicare Advantage bids incorporate numerous assumptions around utilization, provider attribution, network leakage, risk adjustment, quality, and many other factors which vary by market. It is important that an actuary analyze how any potential shift in member mix may impact all of the assumptions that go into the bid.

Understanding provider MACRA strategies and relative coding and documentation capabilities in MA markets now, can provide valuable insights and help leaders proactively manage possible negative MA plan impacts in the future.


About the Author:

MACRA blog 2 compliance comments4_jm 032618Jim Dolstad, ASA, MAAA

Vice President, Actuarial Consulting, Optum

Jim has over 30 years of industry experience serving payers, providers and employers. He has expertise in population health management, program and population assessment, total cost reduction,  and performance management. Prior to joining Optum, Jim served as Chief Actuary for EXL, and as Chief Actuarial Officer for Carewise Health.

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