by Mark L. Hudak, M.D., FAAP,
and Budd N. Shenkin, M.D., FAAP
Two signature pieces of health care reform legislation were passed during the Obama administration,
the Affordable Care Act (ACA) of 2010 and the Medicare Access and CHIP Reauthorization Act of 2015
The ACA focused on reducing the number of Americans without medical insurance through a combination of federally subsidized marketplace plans and a
historic expansion of Medicaid. The ACA also created
the Center for Medicare & Medicaid Innovation to
accelerate achievement of “triple aim” objectives (lower
cost, higher quality, population impact) by evaluating
novel care delivery organizations such as accountable
care organizations (ACOs).
MACRA, unlike the ACA, was passed by Congress
overwhelmingly with bipartisan support. MACRA enabled the Centers for Medicare & Medicaid Services
(CMS) to restructure Medicare payments to physicians
in ways that tied payment to performance as assessed
by cost and quality metrics.
At first glance, since federal policy and MACRA
center on Medicare, the changes would appear to be
irrelevant to pediatricians. But is that a correct inference? We believe not. Even with significant alteration
of the ACA, MACRA will survive because of bipartisan
consensus on better care at lower cost.
Some commercial payers and Medicaid health maintenance organizations already are migrating away from
strict fee-for-service (FFS) payments to pediatricians
toward capitated payments or modified FFS payments
that reward good performance on cost and quality metrics. Pediatricians must become knowledgeable enough
to suggest pediatric adaptations to the adult-centered
reforms as they affect Medicaid, the Children’s Health
Insurance Program and commercial payers. Individual practitioners must anticipate potential changes and
adapt their practices to succeed in a changing environment.
MACRA 101 for pediatrics
The Health Care Payment Learning & Action Network defined four categories of alternative payment
methodologies (APMs) describing the transition
of physician payments to shared risk and popula-tion-based methodologies, proceeding from straight
FFS to full global capitation, with two intermediate
stages. By the end of 2018, CMS expects to distribute a
minimum of 50% of Medicare physician payments via
the category 3 and 4 APMs, with the greatest potential
of return in APMs that have both upside reward and
By 2019, MACRA envisions that every Medicare
physician will assume fiscal risk according to his or her
performance on cost and value. CMS will classify all
primary and specialty care providers as qualifying provider (QP) or Merit Incentive Payment System (MIPS)
physicians based on the proportion of practice patients
insured in 2017 by APMs that expose the physician
to more than minimal fiscal risk. QPs will not only
incur APM risk and/or reward but also will be paid an
automatic 5% bonus on 2019 annual Medicare payments. CMS will evaluate non-QPs (MIPS physicians)
based on a weighted assessment of quality, cost, practice
improvement and electronic health records (EHRs).
Relative rankings will determine end-of-year payment
adjustments ranging from ± 4% in 2019 to ± 9% by
2022. Data submission requirements will be very high
for MIPS physicians, somewhat less so for QPs.
Implications for pediatricians
Most pediatricians already have some experience
with quality, cost, meaningful use, and/or patient satisfaction metrics, but general and subspecialty practices
other than those in ACOs have had little experience
with downside risk.
In most marketplaces, commercial payers likely will
experiment with alternative payment methodologies
in pediatrics, though not urgently, since their pediatric
costs are relatively small. Medicaid, which covers the
costliest children, already has begun experimentation
with new payment methodologies in some states; but
state-to-state variability in Medicaid, coupled with
the growth of Medicaid Managed Care, makes it dif-
ficult to generalize. Without first legislating parity of
physician Medicaid payments to Medicare, we cannot
envision how creating a “reformed” payment system
akin to MIPS — under which many providers will in-
cur reductions to already insufficient payments — will
have anything but a negative impact on most Medicaid
physicians and the children for whom they care.
Whatever their experience with value-based funding,
it will be wise for practices to prepare. Pediatric APMs
likely will adapt the most successful features of Medicare physician payment reform.
Some steps that physicians and practices can take to
anticipate changes in payment methodologies include:
• Acquire and customize an EHR to track, manage
and report quality metrics. Practices should anticipate responsibility for performance related to typical pediatric Healthcare Effectiveness Data and
Information Set (HEDIS) measures (well-child
visits, immunizations and appropriate asthma
medication management) as well as other practices (developmental screens, depression screens)
that add value to health care delivery.
• Be ready to adopt new technologies (as economically rational) that can facilitate timely and appropriate patient access to your practice (e.g.,
telehealth). Use of telehealth might reduce unnecessary emergency department visits and hospitalizations and count for credit under quality
improvement and cost metrics.
• Incorporate population health programs that likely
will be measured: outreach to patients for Bright
Futures well visits and immunization, maintenance of registries, and disease management.
• If not already a patient-centered medical home,
investigate becoming one, as certification may affect contracts and payment.
• Visit the AAP Practice Transformation website,
http://bit.ly/2jzN3dS, regularly to find new or
updated educational materials and guidance related to medical home implementation, practice
efficiency and APMs.
• Consider your organizational options in light of
your local medical geography. Medicare payment
reform is encouraging small stand-alone practices
to become affiliated with or part of a larger group
practice or organization.
Powerful external forces are changing medical practice, and pediatricians must step up. Practices need to
provide good anticipatory guidance to themselves to
prepare for anticipated changes. Look to your organizations, find your leadership, keep up-to-date, keep
active and look ahead. Meeting challenges well should
Dr. Hudak is chair of the
AAP Committee on Child
Health Financing and
chair-elect of the AAP Section of Neonatal-Perinatal
Medicine Executive Committee. Both Drs. Hudak
and Shenkin are members
of the AAP Task Force on Pediatric Practice Change.
What you should know about the transition to value-based payments
Dr. Hudak Dr. Shenkin
2017 CERTIFYING EXAMINATIONS OF THE AMERICAN BOARD OF PEDIATRICS
111 SILVER CEDAR COURT, CHAPEL HILL, NC 27514-1513
Telephone: 919-929-0461 Website: www.abp.org
All applicants for certifying examinations must complete applications online during the registration periods. Registering
during late registration requires payment of a late fee. The requirements for online applications may be found on the American
Board of Pediatrics’ (ABP) website ( www.abp.org), or may be obtained by contacting the ABP. Additional information including
eligibility requirements and registration dates may also be found on the ABP website.
GENERAL PEDIATRICS EXAMINATION: Oct. 16–18, 2017
Registration: Jan. 18, 2017 – April 3, 2017
Late Registration: April 4, 2017 – May 15, 2017
*The ABP, in collaboration with the American Board of Emergency Medicine (ABEM), offers a certificate in Pediatric Emergency Medicine.
**The ABP, in collaboration with the ABEM, the American Board of Family Medicine (ABFM), and the American Board of
Internal Medicine (ABIM), offers a certificate in Sports Medicine.
The ABP, in collaboration with the ABIM, the American Board of Otolaryngology (ABOto), and the American Board of
Psychiatry and Neurology (ABPN), offers certification in Sleep Medicine.
All applicants for the Sports Medicine, Sleep Medicine and Pediatric Emergency Medicine Certifying Examinations must
apply through the Board in which they hold their primary certification. Registration dates may differ for each Board.
• Pediatric Rheumatology Examination: March 29, 2017
• *Pediatric Emergency Medicine Examination: April 3, 2017
• Developmental-Behavioral Pediatrics Examination: April
• Pediatric Hematology-Oncology: April 6, 2017
• **Sports Medicine Examination: July 11-15, 2017
• Child Abuse Pediatrics Examination: Nov. 2, 2017
• Pediatric Endocrinology Examination: Nov. 8, 2017
• Pediatric Infectious Diseases Examination: Nov. 14, 2017
• Pediatric Gastroenterology Examination: Nov. 15, 2017
• Sleep Medicine Examination: Nov. 20, 2017
• Regular Registration: Feb. 1, 2017 – April 3, 2017
• Late Registration: April 4, 2017 – May 1, 2017