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.

This week, Royal Dutch Shell announced that it would postpone oil drilling in the Chukchi Sea and the broader American Arctic indefinitely. The decision came in the wake of disappointing output from its Burger field, the high costs associated with the project (already nearing $7 billion), the “challenging and unpredictable federal regulatory environment in offshore Alaska,” and a growing public relations problem with environmental groups opposed to Arctic drilling.

This decision is a momentous one—both for the future of the U.S. energy policy and the ability of the international oil industry to balance global oil supply and demand. The announcement came only days after Hillary Clinton spoke out against the Keystone Pipeline, not only because it would lead to the consumption of more fossil fuels but also because much of the oil might be exported. With broader opposition to lifting the ban on crude oil exports gaining momentum in the White House, it is clear that at least part of the nation’s political leadership is moving in a nationalistic direction. This means that the United States—with its vast resources—is unwilling to help meet the burgeoning energy needs of the world’s population: especially the 1.2 billion people who have no access to commercial energy.

Shell’s decision highlights four significant and diverse areas of concern for the future of energy globally and energy policy here in the United States.

Mapping supply and demand

Shell and much of the rest of the international petroleum industry had viewed the Chukchi Sea as one of the last great oil frontiers. The Chukchi and adjoining Beaufort Seas are vital for meeting the estimated 12 to 15 million barrels per day (mmbd) of additional oil demand projected by almost all oil forecasts (both inside and outside the industry) needed between 2035 and 2040. 

Without the U.S. Arctic, the other areas projected to make major contributions by this time are Iraq, Iran, Saudi Arabia, shale oil around the world (including North America), the Orinoco region of Venezuela, and the pre-salt offshore Brazil. Needless to say, given the political turmoil in Iraq, Iran, Venezuela, and Brazil—as well as concerns about the long term stability of Saudi Arabia—one has to wonder: Where will the world discover additional, reliable crude oil supplies without a major contribution from the Arctic?

Many in the environmental community argue that we will not need fossil fuels in the future, predicting a turn to renewables, enhanced energy efficiency, large scale battery storage, and electric vehicles. Unfortunately, this has no basis in fact. Clearly renewables will grow exponentially as their prices fall, new technologies will increase energy efficiency, large scale battery storage will commence, and many electric vehicles will hit the road. But there are currently more than 260 million gas and diesel vehicles running on U.S. roads alone, with less than 1 percent of these running on electricity. With transportation fuel demand mushrooming globally, it’s unlikely that oil consumption in the transportation sector will die or even decline significantly. 

Fossil fuels for development

Drilling in the Arctic poses unique environmental risks which must be managed through state-of–the-art technology and accompanied by the most stringent regulatory enforcement. A recent National Petroleum Council examination of all possible challenges involved in Arctic offshore drilling found that drilling can be done safely. Yet despite these findings, most major national environmental groups have opposed any drilling in the Arctic and have even asserted that Shell’s decision is a vindication of their position. But these groups don’t seem concerned or even thoughtful about the long-term implications of the U.S. energy industry’s abandonment of the Arctic.

With the world’s population forecast to rise by 1.6 billion people by 2035, do we really think global oil demand won’t continue to rise? While I recognize that we must do everything to limit the growing use of fossil fuels to attack climate change, do we really have no moral obligation to help countries emerge from poverty, which will almost certainly involve continued use of fossil fuels? 

During his recent visit to America, Pope Francis called for the world to make a renewed commitment to help the “poorest of the poor,” and the United Nations has also put forward new sustainable development goals that include an expansion of energy access to those who are either unserved or underserved. Focusing our policies exclusively on shutting down U.S. fossil fuel development, as some environmental groups advocate, takes away resources that can be used to improve global health, education, clean water, and women’s empowerment—all of which are all directly related to energy access. In looking at girl’s education, for example, increasing energy availability allows water to be pumped up from the river, obviating the need for arduous, tedious work for the women and girls that would otherwise have to carry this water by hand to their communities, limiting time for education. The availability of energy allows vaccines to be safely stored, crops to be refrigerated, and children to have the electricity available to study at night. 

All of these benefits—and many others—cannot happen without improving electricity access, which still involves fossil fuel. The United States can and should play a role in this effort.

Jostling for Arctic access

Shell is not the only company to experience setbacks in the Arctic. Italy’s ENI SpA and Norway’s Statoil ASA just yesterday had another regulatory setback due to delays in obtaining permission from Norway to commence production. In June, a consortium including Exxon and BP PLC suspended its Canadian Arctic exploration, noting insufficient time to begin test drilling before the expiration of its lease in 2020. In addition, Exxon had to curtail its plans to drill in the Russian Arctic after the United States imposed sanctions on Moscow and its energy industry following the annexation of Crimea. 

Russia, though, remains active in the Arctic, and it can be assumed that once sanctions are lifted, many oil companies will try to gain a toehold. China, Korea, India, and Singapore, among other countries, have expressed interest in gaining access to the region’s mineral, energy, and/or marine resources. In several cases, they are building ice-worthy vessels to give them the capability to do so. The Bering Strait is emerging as a significant new maritime route in desperate need of enhanced regulation.

In a report last year, my colleagues and I looked at key recommendations for offshore oil and gas governance as the United States assumed chairmanship of the Arctic Council. Beyond highlighting the resource potential of the region, our work looked at increasing needs for safety and security as a result of increasing transportation across the Arctic. Even as the United States stands to be less involved in Arctic energy development, it is our duty as chair of the Arctic Council to lead in region. 

Alaska is a state, not a park

The promise of the Arctic has inspired adventurers, explorers, geographers, scientists, and entrepreneurs for generations and will continue to do so in the future. The United States should be actively involved in helping to ensure that Arctic resources are developed and used prudently—rather than sit on the sidelines with myopic dreams of leaving the region a pristine wilderness. Arctic inhabitants—both natives and others—of course want to keep the Arctic safe, but they do not want to make it a museum. 

Development of the region’s resources accounts for nearly 95 percent of Alaska’s revenues. If we deny its development, are we prepared to make a line item in the federal budget to pay for Alaska to remain a park? 

In advance of President Obama’s trip to East Africa on July 23, the Africa Growth Initiative has prepared short travel companions on the economic environments in both Ethiopia and Kenya. The president’s visit to Kenya, one of the larger economies on the continent and a major driver of growth in the East Africa region, underlies the United States’ commitment to trade and investment on the continent. Below are key facts on Kenya’s economy to consider as President Obama travels to the region. Facts on Ethiopia can be found here.

Kenya enjoys middle-income status. Earlier this month the World Bank confirmed Kenya’s lower-middle-income country status according to their latest estimates of the gross national income per capita. This followed from the statistical reassessment of GDP figures that increased the size of its economy by 25 percent  ($53.3 billion up from $42.6 billion) last September, making it the continent’s ninth-biggest economy, accounting for over 2 percent of the continent’s GDP.

Kenya has undertaken initiatives to attract private sector investment. According to the late Brookings Senior Fellow Mwangi Kimenyi, the nation’s strong private sector evolved under relatively market-friendly policies for most of the post-independence era. Foreign direct investment is further expected to take the lead in growth acceleration, especially in the extractive sector if the newly discovered oil deposits are found to be commercially viable. Large-scale infrastructure projects, such as the Mombasa-Kigali standard-gauge railway and the Lamu Port and Southern Sudan and Ethiopia Transport (LAPSSET) corridor, also incentivize private sector engagement. Kenya has been among the top recipients of external financing for infrastructure investment during 2009-2012, primarily led by Private Participation in Infrastructure (PPI) Financing.

Kenya was the first African country to build geothermal energy sources. Geothermal energy provides 51 percent of Kenya’s energy, allowing electricity bills to decrease by 30 percent since 2014 (World Bank).

Kenya acts as a hub for regional integration and the East African Community (EAC). Among the six Country Policy and Institutional Assessment (CPIA) indicators of the African Development Bank, infrastructure and regional integration registered the score of 4.6 in Kenya, the second best in Africa. As a regional export and financial hub, Kenya plays a leading role in the EAC and regional integration. Two Kenyan cities, Nairobi and Mombasa, are the biggest city and port (respectively) between Cairo and Johannesburg, making Kenya the commercial and transportation hub of East Africa.

Kenya has experienced service-led growth over the last decade. Kenya’s market-based economy enjoys some of the strongest service-sector industries, including the financial and the information and communication technology sectors, which play key roles in economic transformation and job creation in Kenya. Besides, travel and tourism made up 12.1 percent of Kenya’s GDP in 2013, and the nation is frequently cited as one of the best tourist destinations in Africa.

More than two-thirds of the adult population engages in mobile commerce, making Kenya the world leader in mobile payments. At 86 percent mobile payments penetration among Kenyan households, M-Pesa is redefining the way Kenyans perform transactions and has also facilitated financial inclusion by promoting savings and financial transactions among the unbanked.

Nearly one out of every two women in Kenya is a member of a women’s saving group, which are voluntary groups formed to  help women overcome barriers to financial participation. Called chamas, these groups allow women to mobilize savings and collectively invest to improve their livelihoods by contributing a certain amount of money to a pooled fund.

Kenya has a thriving manufacturing sector. Kenya is slowly diversifying exports away from agricultural commodities and increasing value-added processing. In 2014, roughly 70 percent of Kenya’s exports to the U.S. were textile- and garment-based, in which the African Growth and Opportunity Act (AGOA) has played a key role. The recent extension of AGOA for another decade opens up further opportunities for growth and revival of the textile and apparel industry in Kenya.

Kenya’s well-diversified economy and sound economic reform program are important steps in its quest to reach emerging market status. However, the following key challenges could undermine economic development:

Youth in Kenya are experiencing much higher unemployment rates than the rest of the Kenyan population. Though Kenya boasts of its young, educated and English-speaking human resource pool (especially in the urban areas), it continues to struggle with high unemployment rate among young people, which is estimated to be double the national level of unemployment of 12.7.

Spatially unbalanced growth in the Kenyan economy continues to be evident. Kenya has made substantial progress towards achieving towards achieving the targets associated with the Millennium Development Goals, including child mortality and near universal primary school enrolment. However, it still has a long way to reach the set targets: Over 40 percent of its 44 million population continues to be extremely poor living on less than $1.25 a day, with women being particularly at risk.

Implementation challenges of fiscal decentralization remain. Under the new constitution, county governments are entitled to not less than 15 percent of the total national revenue collected by the Kenyan central government. This fiscal devolution can bolster social cohesion, by increasing accountability in the management of public resources, and improving the quality of services delivery. However, it is crucial that this devolution is implemented successfully with equitable access to resources to all parts of the country. AGI’s Kenya Devolution and Revenue Sharing Calculator serves as a web interactive allowing users to explore and adjust the government of Kenya’s allocation formula for revenue distribution to county governance structures.

Kenya’s infrastructure remains insufficiently developed in spite of the fact that over the last five years, nearly 27 percent of the national budget has been allocated to transport, energy, water and sanitation, and environment-related infrastructure. Kenya was a pioneer in the use of infrastructure bonds in Africa, with its first issuance in 2009 of a 12-year bond which raised $ 232.6 million but further substantial investment in infrastructure is critical to achieving  Kenya Vision 2030 to become a globally competitive country.

On August 26, the Brookings Institution hosted a panel discussion of the findings of the 2015 Financial and Digital Inclusion Project Report and Scorecard. Chief among the report’s findings was the rapid growth of financial products and services targeted at the world’s unbanked population.  Much of the growth stems from innovations in digital payments systems and non-bank financial services.  For example, systems like M-Pesa in Kenya allow customers to store money on their mobile phones and easily transfer it to other M-Pesa users.  Advancing financial inclusion will greatly benefit the two billion people worldwide that still lack access to any financial services.

The report itself ranks a set of 21 countries on four continents chosen for their efforts to promote financial inclusion.  The criteria used to score each country include country commitment, mobile capacity, regulatory environment, and adoption.  The results show that several pathways to financial inclusion exist, from mobile payments systems to so-called “branchless” banking services.  Places that lack traditional banks have seen financial inclusion driven by mobile operators, while others have experimented with third-party agent banking in areas that lack bank branches.   

The panel drew financial inclusion and mobile payments experts from the government, industry, and non-profit groups.  Each panelist touted the benefits of financial inclusion from their own perspective.  Women especially have much to gain from financial inclusion since they have historically faced the most obstacles to opening financial accounts.  In developing countries, a mobile payments system grants women greater privacy, control, and safety compared to cash payments.  Traceable digital payments also make it easier to combat corruption and money laundering.  Salaries paid to government employees and transfer payments to low-income households can be sent straight to a mobile payment account, eliminating opportunities for bribe seeking and theft. 

According to the panelists, financial inclusion can also drive economic growth in developing countries.  As financial services expand, they will also increase in sophistication, allowing customers to do more with their money.  For example, a payments record can be used to establish a credit history for loan applications, and digital savings accounts with interest can help customers protect their wealth against inflation.  These same systems can also be used to provide insurance coverage, reducing financial uncertainty for low-income populations.

The proliferation of financial services has many benefits, but it will also create policy challenges if regulations do not keep up with financial innovation.  Requiring several forms of identification to purchase a mobile phone or open a bank account presents an obstacle to low income and rural customers that live far away from government offices that issue identification. Broad coordination between telecom regulators, ID issuers, banking authorities, and other government agencies is often necessary for lowering barriers to accessing financial services.

It is telling that many countries included in the report are looking to other developing countries for policies to promote financial inclusion.  The scarcity of traditional banks combined with new methods of accessing financial services opens avenues to financial inclusion not seen in most developed countries. Established banking industries and the accompanying regulations leave fewer opportunities for financial innovation, but countries with large unbanked populations can start with a clean slate. Over the next two years, FDIP will continue to monitor and report on developments in financial inclusion around the world.

Send comments on the 2015 FDIP Report and Scorecard and suggestions for future reporting to FDIPComments@brookings.edu.

Editor’s Note: Brookings will hold an event and live webcast on Thursday, August 4 to discuss the findings of the forthcoming 2016 Financial and Digital Inclusion Project (FDIP) Report. Follow the conversation on Twitter using #FinancialInclusion.

The 2016 Brookings Financial and Digital Inclusion Project (FDIP) Report, the second annual report produced by the FDIP team, assesses national commitment to and progress toward financial inclusion through traditional and digital mechanisms in 26 countries.  

As in the 2015 report, the FDIP team analyzed four key dimensions of financial inclusion: country commitment, mobile capacity, regulatory environment, and adoption of formal financial services. The 2016 report amplifies the geographic diversity of the FDIP country sample by adding five new countries and features descriptions of the financial inclusion landscape in all 26 countries.

The 2016 FDIP Report finds that significant progress has been made toward advancing financial inclusion in many countries, and robust commitment to strengthening the digital financial services ecosystem is evident across diverse geographic, political, and economic contexts.

On August 4, the Center for Technology Innovation will discuss the key findings of the 2016 FDIP Report and host a conversation with public sector representatives about key trends, opportunities, and obstacles regarding financial inclusion in their respective countries and around the world.

Below we provide some context regarding the role of financial inclusion within the global drive for sustainable development.

What is financial inclusion?

The common themes that emerge from many definitions of financial inclusion are the ability to access formal financial services and to utilize those services in a way that promotes financial health.

For example, the Center for Financial Inclusion at Accion defines financial inclusion as a “state in which everyone who can use them has access to a range of quality financial services at affordable prices, with convenience, dignity, and consumer protections, delivered by a range of providers in a stable, competitive market to financially capable clients.”

In short, financial inclusion in itself is not the end goal, but instead serves as a key mechanism for advancing the well-being of individuals, families, and communities. At the macroeconomic level, financial inclusion provides opportunities to advance economic growth, reduce income inequality, and combat poverty.

For the purposes of FDIP, we primarily focus on individuals’ access to and usage of affordable, secure, basic financial services and products, such as person-to-person payments and savings accounts. However, we also recognize the important role that more extensive financial services (e.g., microinsurance and microcredit) can play in enabling individuals to plan for the future and absorb financial shocks. Where possible, we highlight examples of a broad suite of financial services within the country profiles of the 2016 report.

To learn more about the 2016 FDIP Report, please register to attend the launch event in-person or watch the live webcast.