On January 1, 2017, CMS will implement the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). After months of talking to physicians across the country, with an emphasis on small and rural non-hospital-based physicians, CMS released the final rule on October 14, 2016 (Livingston, Shelby, 2016) (Health and Human Services, 2016). To read the 2015 legislation, visit Congress.gov. For the final rule, visit cms.gov. Additional resources are listed at the end of this blog.
To summarize, MACRA replaces three other CMS quality data programs (PQRS, Meaningful Use, and Value-Based Modifier) with a single Quality Payment Program. In addition, MACRA eliminates the Sustainable Growth Rate formula (SGR) by replacing the 1997 penalty-based system which would have cut fees for all services across the board every year, if not blocked by Congress in an annual nail-biting ritual (Stuart Guterman, 2015) that came to be known as “doc fix”. According to CMS, 2015 would have seen a 21% cut in Medicare payments to clinicians if the doc fix had not been passed (Center for Medicaid & Medicare Services). Instead, a small annual inflation-based fee increase will be coupled with incentives and penalties based on performance.
The new Quality Payment Program has two tracks. Medicare Part B providers may be in one, both, or neither. The QPP tracks are:
MIPS performance scores are based on the following general areas:
To get started exploring the measures selected in each category for the Quality Payment Program, visit the new Medicare QPP website.
Under MACRA, Advanced Alternative Payment Models refer to specific payment models run by CMS which satisfy certain additional requirements. Under APMs, the clinic or physician bears some financial risk. MACRA provides incentive payments for participation in APMs. For more details on which APMs are incentivized under MACRA, see SA Ignite’s FAQ.
Impact of EHR Use on Your Score
The Advancing Care Information component of the QPP, which deals with health IT, encompasses 25% of your total MIPS performance score. However, it is only 25%. By focusing on your top six Quality Measures now, which account for 50% of your score, you can move your practice a long way towards being ready when reporting starts in 2017. But get ready. By 2018, the use of certified EHR technology will be mandatory. You can search the official Certified Health IT Product List to see whether your EHR or one you are considering, is certified: CHPL Search.
Support for Small Practices
CMS projects that more small practices will participate in the Quality Payment Program than in the older programs, because, they claim, there will be a “reduced reporting burden, increasing usability of technology, and stepped-up technical assistance” (Center for Medicaid & Medicare Services, 2016). The law provides $20 million each year for five years to provide training and education to Medicare providers in practices of 15 or fewer clinicians or those working in underserved areas. This funding is intended to provide support across the board, including the area of health IT.
Alternatives to Participation in MACRA
Small and individual practices do have options to participating in MACRA, however these options involve completely changing how your practice is structured:
Government interference and healthcare “reforms” will not be coming to an end. The rate of new regulation and its impact on small practices continues to grow. Out of frustration, more and more physicians opt to become employed and give up trying to run their own independent practices in this environment. Every time this happens, the patients suffer. More and more independent practices are turning to alternative payment models, and finding greater satisfaction in their work by opting out of a system that they are powerless to change.
Additional Resources on MACRA
Estimate the financial impact of MIPS with a free calculator
Quality Payment Program Fact Sheet
Where to Find Help
Small Practice Fact Sheet
Comprehensive List of APMs
Learn More About Improvement Activities and APMs
Center for Medicaid & Medicare Services. (2016, October 14). QPP_Small_Practice.pdf. Retrieved from qpp.cms.gov: https://qpp.cms.gov/docs/QPP_Small_Practice.pdf
Center for Medicaid & Medicare Services. (n.d.). The Merit-based Incentive Payment System: MIPS Scoring Methodology Overview. Retrieved from cms.gov: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf
Health and Human Services. (2016, October 14). HHS finalizes streamlined Medicare payment system that rewards clinicians for quality patient care. Retrieved from https://www.hhs.gov/about/news/2016/10/14/hhs-finalizes-streamlined-medicare-payment-system-rewards-clinicians-quality-patient-care.html
Livingston, Shelby. (2016, October 13). MACRA final rule is set to drop, maybe even this week. Modern Healthcare. Retrieved from http://www.modernhealthcare.com/article/20161013/NEWS/161019948
SA Ignite. (2016, April 27). 10 FAQS About the Merit-Based Incentive Payment System (MIPS). Retrieved from http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips
Stuart Guterman. (2015, April 15). With SGR Repeal, Now We Can Proceed with Medicare Payment Reform. To The Point. Retrieved from http://www.commonwealthfund.org/publications/blog/2015/apr/repealing-the-sgr
Kimberly A. Sherman, MA, CPC - Reimbursement warrior and HIPAA guru.