The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law in 2015 and permanently eliminated the sustainable growth rate (SGR). In April 2016, the Department of Health and Human Services issued a Notice of Proposed Rulemaking to implement key provisions of MACRA. These changes would work via the “Quality Payment Program,” which includes two paths:
For small or rural practices that face different challenges in the implementation of MACRA, CMS has provided a guide on how Quality Payment Programs have been accommodated to fit their needs.
Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS. This framework allows for increased physician flexibility by allowing clinicians to choose the measures and activities appropriate to the care they provide. Measurements begin in January 2017, with payments beginning in 2019.
Four Performance Categories
1. COST: 10% of total score in year 1
2. QUALITY: 50% of total score in year 1
3. CLINICAL PRACTICE IMPROVEMENT ACTIVITIES: 15% of score in year 1
4. ADVANCING CARE INFORMATION: 25% of score in year 1
Clinicians who participate to a sufficient extent in Advanced APMs would be exempt from the MIPS payment adjustment and would additionally qualify for a 5% Medicare Part B incentive payment. To receive these payments, clinicians would need to receive enough of their revenue or see enough of their patients through Advanced APMs.
Advanced APMs are the CMS Innovation Center models, Shared Savings Program tracks, or statutorily-required demonstrations where clinicians accept both risk and reward for providing high quality and efficient care. Criteria for payment based on quality measurement and the use of EHRs must also be met.
The proposed rule includes a list of models that qualify:
Additionally, starting in 2019, clinicians would qualify for incentive payments based on participation in Advanced APMs developed by non-Medicare payers (private insurers or state Medicaid programs). The proposed rule also establishes the Physician-Focused Payment Technical Advisory Committee to review and assess physician-focused payment models.
In order to determine if a clinician meets the requirement for the Advanced APM track, all clinicians will report through MIPS in the first year.