The Centers for Medicare and Medicaid Services (CMS) has published its much-anticipated proposed rule to implement the Medicare Access and Childrens’ Health Insurance Program (CHIP) Reauthorization Act (MACRA), which replaces the Sustainable Growth Rate formula for how fee-for-service or traditional Medicare pays physicians and other clinicians. After annual increases of 0.5% this year through 2019, clinicians will only receive increased Medicare payments through either a Merit Incentive Payment System (MIPS) or through participation in Advanced Alternative Payment Models (APMs). Medicare clinicians meeting the MIPS requirements would receive an additional 4 percent incentive payment beginning in 2019, increasing to 9 percent by 2022. However, for those Medicare physicians who do not meet the new MIPS requirements, MACRA would penalize them up to the same 9 percent. Medicare clinicians meeting the Advanced APM requirements would not be eligible for the MIPS incentives (nor subject to any penalties) and receive an additional 5 percent annual incentive payment beginning in 2019. CMS is calling the new payment mechanisms its Quality Payment Program (MACRA QPP).
The MIPS will combine and replace the existing Physician Quality Reporting System, Physician Value-Based Payment Modifier, and Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals. Under the proposed rule, the MIPS will include payments for:
- Quality (50 percent of total score in year 1): For this category, Medicare clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices; the final list of measures would be published by November 1 of the preceding year
- Advancing Care Information (25 percent of total score in year 1): For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.
- Clinical Practice Improvement Activities (CIPAs) (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities (performed for a minimum of 90 days) that match their practices’ goals from a list of more than 90 options (an “inventory” that includes achieving health equity, integrated behavioral and mental health, and emergency preparedness and response). There would be no minimum number of CIPAs required in year 1.
- Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims using two measures: total per costs capita for all attributed beneficiaries and Medicare spending per beneficiary; there would be no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.
Among the most significant of the changes proposed by the rule is a change to the Medicare EHR Incentive Program. Rather than implementing Stage 3 requirements (currently scheduled for implementation beginning in 2017), MIPS’ Advancing Care Information requirements would:
- Align with the Office of the National Coordinator for Health Information Technology’s 2015 Edition Health IT Certification Criteria
- Simplify reporting by no longer requiring all-or-nothing EHR measurement or quality reporting, but revert to a full year reporting requirement rather than a 90-day reporting period
- Reduce the number of quality measures to an all-time low of 11 measures, down from 18 measures; no longer require reporting on the Clinical Decision Support and the Computerized Provider Order Entry measures
- Allow physicians and other clinicians to choose to select the measures that reflect how health IT best suits their day-to-day practice
- Emphasize interoperability, information exchange, and security measures; and promote use of APIs (application program interfaces, or third party programs) that allow patients to access to their health information
- Exempt certain physicians from reporting when EHR technology is less applicable to their practice, and allow physicians to report as a group.
- Apply these Advancing Care Information requirements to Medicare clinicians (nurse practitioners, physician assistants, clinical nurse specialists, etc.) who have not been eligible to participate in the Medicare EHR Incentive Program for reporting purposes in year 1 in order to assess how the requirements would be applied in future years
There would not be a parallel change to Stage 3 requirements for eligible providers through the Medicaid EHR incentive program (which continues for some Medicaid providers through 2021), nor to Stage 3 requirements for hospitals under either the Medicare or Medicaid EHR Incentive Programs.
The rule proposes that MIPS payment adjustments for 2019 (year 1 of implementation) be calculated using 2017 as the performance year, but payment adjustments be calculated using one’s 2018 payment history. According, the implementation of MACRA would essentially begin in just eight months, on January 1, 2017. The proposed rule notes that the Assistant Secretary for Planning and Evaluation is conducting studies on the issue of risk adjustment for socioeconomic status on quality measures and resource use, but does not expect to make recommendations until October 2016. Given these timelines, it is unlikely that such risk adjustment will be included in the proposed first performance year. Quality measure performance data for Medicare eligible clinicians participating in MIPS would become publicly available on CMS’ Physician Compare website.
In the fiscal impact section of the proposed rule, CMS estimates that between 687,000 and 746,000 Medicare clinicians will participate in MIPS in 2019, and that half would receive bonus payments totaling $833 million, while the other half would receive penalties totaling the same amount. However, CMS estimates that solo practitioners would be penalized $300 million and only receive $105 million in bonus payments, while clinicians in groups of 100 or more would receive $529 million in bonus payments and only $57 million in penalties.
Under the proposed rule, Advanced APMs will include Medicare Shared Savings Program Accountable Care Organizations (ACOs)(Tracks Two and Three, with downside risk), Next Generation ACOs, some CMS bundled payment programs, patient-centered medical homes, and the recently announced Comprehensive Primary Care Plus initiative. While most of these programs are funded by or supported by CMS, the proposed rule includes a definition of patient-centered medical homes as one recognized by a national quality organization (National Committee for Quality Assurance, Joint Commission, Accreditation Association for Ambulatory Health Care, or URAC) or a state Medicaid program. Other Payer Advanced APMs also will be recognized (through Medicaid, commercial, or all-payer models) if they meet detailed criteria, including use of certified health IT, payments tied to MIPS quality measures, and financial risk sharing.
Medicare physicians and clinicians, called qualifying participants (QPs), would be eligible for incentive payments if 25 percent or more of their Medicare payments are paid through an Advanced APM, or 20 percent or more of one’s patients are Medicare beneficiaries. These percentage thresholds will increase over time. CMS estimates that between 30,658 and 90,000 qualifying participants would receive between $146 million and $429 million in APM incentive payments in 2019.
The proposed rule does not describe how technical assistance will be made available to Medicare clinicians as required by MACRA, stating that regulatory guidance on that topic will be issued separately.
Comments on the proposed rule are due by June 27, 2016.
CMS also has created a video explaining MACRA:
Ignatius Bau 