Improving the labor market and encouraging work are central to our goals of achieving greater responsibility and opportunity in America. The private economy is the arena where most Americans work hard to realize their dreams.

But employment today is failing to achieve the promise it did a few decades ago. Wages of unskilled workers have been fairly stagnant in real terms (especially among men) and have fallen relative to those of more-educated workers; and some groups of Americans (like less-educated men generally and black men, specifically) are working considerably less than they once did.

Stagnant wages and low work participation among some groups of workers are blocking progress. Both must be addressed.

In Chapter 4 of a new report from the AEI-Brookings Working Group on Poverty and Opportunity, the Working Group recommends policies that:

1. Expand opportunities for the disadvantaged by improving their skills;
2. Make work pay better than it does now for the less educated;
3. Expand both work requirements and opportunities for the hard-to-employ while maintaining an effective work-based safety net for the most vulnerable members of our society, especially children; and
4. Make more jobs available.

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Editor’s Note: This analysis is part of The Leonard D. Schaeffer Initiative for Innovation in Health Policy, which is a partnership between the Center for Health Policy at Brookings and the USC Schaeffer Center for Health Policy and Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) just over a year ago signaled a strong and unique bipartisan agreement to move towards value-based care, but until recently, many of the details surrounding how it would be implemented remained unknown. But last week, the Centers for Medicare and Medicaid Studies (CMS) released roughly 1,000 pages that shed more light on how physician payment will hopefully dramatically change for the better.

Some Historical Context

Prior to MACRA, how doctors were paid for providing care to Medicare patients was subject to a reimbursement formula known as the Sustainable Growth Rate (SGR). Established in 1997 to control the rate of increase in spending on physician services, the SGR pegged total spending among all Medicare-participating physicians to an overall budget target. Yet in this “tragedy of the commons,” no one physician benefitted from her good stewardship of health care resources. Total physician spending often exceeded the overall budget target, triggering reimbursement rate cuts. However, lawmakers chose to push them off into the future through what were called “doc fixes,” deferring the rate cuts temporarily. The pending cut rose to over 21 percent before MACRA’s passage as a result of compounding doc fixes.

Moving Forward with MACRA

When it was signed into law on April 16, 2015, MACRA ended the SGR, its cuts, and many previous payment incentive programs. In their place, MACRA established two overarching payment incentive schemes for providers to choose from:

1. the Merit-Based Incentive Payment System (MIPS) program, which supplants three previous payment incentives and makes positive or negative adjustments to a physician’s payment based on her performance; or


2. the Alternative Payment Model (APM) program, which awards a 5 percent bonus through 2024—with higher annual payment updates thereafter—for having a minimum percentage of Medicare and/or all-payer revenue through eligible APMs. Base physician fee rates for all Medicare providers would be updated 0.5 percent for each of the first four years, followed by no increases until 2026, when base fees would increase at different rates depending on the payment incentive program in which a physician participates.

MIPS addresses providers’ longstanding complaints that reporting that reporting under the existing programs—the Physician Quality Reporting System, the Value-Based Modifier, and Meaningful Use — is duplicative and cumbersome. Under the new MIPS program, physicians report to the government payer directly (CMS) and receive a bonus or penalty based on performance on measures of quality, resource use, meaningful use of electronic health records, and clinical practice improvement activities. The bonus or penalty physicians may see starts at 4 percent of the fee schedule in 2019 (based on their performance two years prior—in this case 2017) and increases successively to 5 percent in 2020, 7 percent in 2021, and 9 percent from 2022 onward. From 2026 onward, MIPS providers would receive an annual increase of 0.25 percent on their base fee schedules rates.

In contrast, the APM incentive program awards qualifying physicians a fixed, annual bonus of 5 percent of their reimbursement from 2019- – 2024, and provides that their fee schedule rates grow 0.5 percentage points faster than those of MIPS in 2026 and beyond, in recognition of the risk they assume in these contracts.

Yet, according to MACRA, not all APMs are created equal. APMs eligible for this track must use quality measures similar to those of MIPS, ensure electronic health records are used, and either be an approved patient-centered medical home (PCMH) or require that the participating entity “bears more than nominal financial risk” for excessive costs. Then, in order to receive the APM track bonus, physicians must have a minimum of 25 percent of their revenue from Medicare come through eligible APMs in 2019, with the minimum increasing through 2023 up to 75 percent. In 2021, a new all-payer Advanced APM option becomes available, allowing providers in APM contracts with other payers to participate in the Advanced APM incentive. To do so, they must meet the same minimum thresholds—50 percent in 2021, 75 percent in 2023—but through all provider contracts, not solely Medicare revenue, while still meeting a significantly lower Medicare-specific threshold. By creating an all-payer option, CMS hopes to enable greater provider participation by allowing all payer revenue to count toward the same minimum threshold. Under the all-payer model in 2021, for example, providers must have no less than 25 percent of Medicare revenue through Advanced APMs and 50 percent of all revenue through Advanced APMs.

MACRA Implementation Details Revealed

The newly released proposed rule provides answers to significant questions that had been left unanswered in the law surrounding the specifics of implementation of MIPS and the APM incentives. At long last, providers are gleaning insight into how CMS intends to implement MIPS and the APM track. Given the fast-approaching MIPS performance period in January 2017, here are three key highlights providers need to know:

1. Qualifying for the APM incentive track—and getting out of MIPS—will be difficult. In order to qualify for the bonus-awarding Advanced APM designation, APMs must meet the “nominal financial risk” criteria, which will be measured in three ways: an APM’s marginal rate sharing for losses, minimum loss ratio (the threshold above which providers would begin sharing in losses), and total potential risk as a percent of expected costs. Clinicians must further have a minimum share of revenue that comes in through the designated APMs.


2. Providers will have fewer opportunities to see and improve their performance on MIPS. Despite calls from provider groups for more frequent reporting and feedback periods, MIPS reporting periods will be annual, not quarterly. This is true for performance feedback from CMS, as well, though they may explore more frequent feedback cycles in the future. Quarterly reporting and feedback periods could have made the incentive programs more “actionable” for providers, alerting them to their performance closer to the time the services were rendered and providing more opportunities to improve performance.


3. MIPS allows greater flexibility than previous programs. Put simply, MIPS is the performance incentive program clinicians will participate in if not on the Advanced APM track. While compelling participation, the proposed MIPS implementation also responds to stakeholder concerns that earlier performance incentive programs were onerous and sometimes irrelevant—MIPS reduces the number of measures required in some categories and allows physicians to select from a set of measures to report on based on relevancy to their practice.

With last week’s release of the proposed rule, the Leonard D. Schaeffer Initiative for Innovation in Health Policy is kicking off a series of work products that will focus dually on further MACRA implementation issues and on translating complex policy into providers’ experience. In the blogs and publications to follow, we will dive into greater detail and discussion of the pieces of MACRA implementation highlighted here, as well as many other emerging physician payment reform issues, as the law’s implementation unfolds.

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In recent decades, India has taken on a growing global presence, one that has been seen as increasing even more since Prime Minister Narendra Modi took office nearly two years ago. In a new book, “India at the Global High Table: The Quest for Regional Primacy and Strategic Autonomy” (Brookings Institution Press, 2016), former U.S. ambassadors Teresita Schaffer and Howard Schaffer explore how India is managing its evolving international role, assessing the country’s strategic vision and foreign policy, and the negotiating behavior that links the two.

On April 20, The India Project at Brookings hosted a panel discussion to discuss the book and, particularly, four elements highlighted in it: India’s exceptionalism; its nonalignment and drive for “strategic autonomy;” its determination to maintain regional primacy; and, more recently, its surging economy.

Join the conversation on Twitter using #IndiaHighTable

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This keynote presentation by Bruce Katz at City Hall in Seattle describes how a vibrant center city stimulates a region's economy. The presentation also assesses how Seattle is faring on this front and what steps the city should take as it looks to the future.

The metro program hosts and participates in a variety of public forums. To view a complete list of these events, please visit the metro program's Speeches and Events page which provides copies of major speeches, powerpoint presentations, event transcripts, and event summaries.

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INTRODUCTION

Economic inequality has been on the rise in America for more than three decades. The nation’s traditional engine for promoting equality and opportunity—its public education system—has been unable to halt that upward trend despite increased public spending at the preschool, K–12, and postsecondary levels. Meanwhile, accumulating research evidence reveals that postsecondary education has, for the past few decades, proved an increasingly powerful tool in boosting the income and economic mobility of disadvantaged students. Here we outline steps that high schools can take to increase the college readiness of poor and minority students, making it more likely that they will be accepted into and graduate from college.

The annual income difference between Americans with a college degree and those with a high school degree was more than $33,000 in 2007, up from $12,500 in 1965. More to the point, long-term intergenerational data from the Panel Study of Income Dynamics show that a college degree helps disadvantaged children move up the income distribution past peers in their own generation. Adult children with parents in the bottom fifth of income, for example, nearly quadruple (from 5 percent to 19 percent) their chance of moving all the way to the top fifth by earning a college degree.

But too few poor kids get a college degree. About one-third of all youngsters from the bottom fifth of family income enter college and only 11 percent get a degree. By contrast, 80 percent of those from the top fifth enter college and well over half earn a degree.

Perhaps the primary reason that poor and minority students do not enter and graduate from college is that they are poorly prepared to do well there. The problem is especially evident in the huge gap between the academic achievement of white, Asian, and middle- and upper-income students as compared with black, Hispanic, and low-income students. And decades of educational reform aimed at reducing this gap have had, at best, modest success. Striking evidence of how few college freshmen meet even the most basic college preparation standards is provided by Jay Greene and Greg Forster of the Manhattan Institute. Defining minimum college readiness as receiving a high school diploma, taking courses required by colleges for basic academic preparedness, and demonstrating basic literacy skills, Greene and Forster report that only around 40 percent of white and Asian students were college ready by these criteria. But that figure was twice the 20 percent rate for black students and more than twice the 16 percent rate for Hispanic students.

The latest issue of The Future of Children, devoted to exploring how to improve America’s high schools, contains several articles that touch on student preparation for postsecondary education and the world of work. An especially compelling article, written by Melissa Roderick, Jenny Nagaoka, and Vanessa Coca, of the Consortium on Chicago School Research at the University of Chicago, contains a careful analysis of how to measure whether students are ready for college and a host of proposals for actions high schools can take to increase their students’ readiness for postsecondary education. As the Roderick article and related research and analysis make clear, recent years have seen an upsurge of support for the goal of helping all students, but especially poor, urban, and minority students, prepare for college, enter college, and earn a terminal degree. Attaining that goal, we believe, would boost economic mobility in the United States and help the nation live up to its ideals of equality of educational and economic opportunity.

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