MACRA update

What Does the Medicare Quality Payment Program Mean to Me Now?

  • The Quality Payment Program will apply to almost all rheumatologists accepting traditional Medicare. Quality reporting programs currently required under traditional Medicare will be phased out and replaced with the Merit-Based Incentive Payment System (MIPS). The new program will take effect in 2017, at which point the performance measurement will begin, but payment modifications will not occur until 2019. For most UR members, this will not represent a significant departure from existing Medicare payment modifiers, and if you are in good shape for current programs (PQRS, Meaningful Use, and Value-Based Payment Modifier), you will be in good shape for MIPS.
  • CMS recently announced flexibility to help providers avoid negative payment adjustments in the first year, dubbed “Pick Your Pace,” which will likely allow providers, at minimum, to avoid negative payment adjustments for simply reporting data in the first year. However, we are awaiting the Final Rule, anticipated for release sometime in October or November.
  • Special payment bonuses of five percent will be available to participants in Advanced Alternative Payment Models (A-APMs); so far, the options available to rheumatologists and most specialists are limited, but CMS is likely to expand A-APM options over the coming years, as has been seen with programs such as the Oncology Care Model.

What is MACRA and what is the “Quality Payment Program”?

The Medicare Access and CHIP Reauthorization Act (MACRA) was passed by Congress in the spring of 2015, repealing the Sustainable Growth Rate (SGR), the flawed system by which providers’ Medicare fee for service rates were updated annually. MACRA replaces the SGR with a system tying updates to quality metrics and participation in “Alternative Payment Models.”  CMS is calling the new system under MACRA the “Quality Payment Program.” The Quality Payment program will apply to almost all rheumatologists accepting traditional Medicare, excluding only those under low patient or revenue thresholds, or those new to the Medicare program. The program is due to go into effect in 2017, with the first payment impacts occurring in 2019.
In Years 1 and 2, physicians, PAs, NPs, clinical nurse specialists, and certified registered nurse anesthetists will be affected. To see more about the potential broadening of participating clinicians in Year 3 and beyond, see slide 13 of the CMS Quality Payment Program presentation.  Note that MACRA and the Quality Payment Program do not apply to Medicare Advantage.
See CMS’s proposed timeline for payment adjustment.
 

How will payment updates and incentives work under MACRA?

CMS issued a detailed Notice of Proposed Rulemaking in April of 2016 outlining proposals for how the program will work.All providers will be placed into one of two new payment tracks: (1) the Merit-Based Incentive Payment System (MIPS); or (2) the Advanced Alternative Payment Models (A-APMs) track. Most providers, including most rheumatologists, will be assessed under MIPS. On September 9, CMS announced that it will offer more flexibility to providers in an option it has dubbed “Pick Your Pace.” This flexibility will not delay the start date of the payment reform, but will modify the proposals to: (1) allow safe harbors from negative payment adjustments in the first year of MIPS to providers who submit any data at all; and (2) allow partial as well as full-year data to be submitted for the first year of MIPS.
See CMS’s overview of the proposed rule.
See Andy Slavitt’s September 8 post on the CMS blog announcing new MACRA options.
 

Provider Reactions

Throughout the summer, CMS came under repeated criticism for the complexity of the proposals, as well as pressure from the provider community to offer hardship exemptions and other safe harbors from downside payment adjustments, particularly for small and rural providers. The American College of Rheumatology wrote a comment letter expressing concerns, including that there are not yet enough Alternative Payment Model options for rheumatologists.
See ACR’s comments in response to the April 27, 2016 proposed rule.

What does this all mean for me and for United Rheumatology (UR)

While, for most UR members, MACRA will not represent a significant departure from existing Medicare payment modifiers in the short term, it is important that practices resolve any existing gaps in their ability to report successfully to these programs, and therefore avoid penalties. Longer term, the effects of MACRA may be much more significant, since they will shape the growth of Alternative Payment Models within the traditional Medicare program. UR is interested in being part of the national conversation about rheumatologists’ participation in such models.
 
The MACRA final rule has not yet been released, but is currently under review by the Office of Management Budget (OMB), signaling it may be close to release. As UR receives additional information, it will continue to keep you apprised.
Reported by Inside Health Policy (subscription service) on September 15, 2016.
 


In Years 1 and 2, physicians, PAs, NPs, clinical nurse specialists, and certified registered nurse anesthetists will be affected. To see more about the potential broadening of participating clinicians in Year 3 and beyond, see slide 13 of the CMS Quality Payment Program presentation.  Note that MACRA and the Quality Payment Program do not apply to Medicare Advantage.

  • CMS’s proposed timeline for payment adjustment.
  • CMS’s overview of the proposed rule.
  • Andy Slavitt’s September 8 post on the CMS blog announcing new MACRA options.
  • CMS’s page on the Physician Quality Reporting System (PQRS).
  • CMS’s page on EHR Incentive Programs.
  • CMS’s page on the Value-Based Payment Modifier.

Advanced APM models include the Medicare Shared Savings Program (MSSP) Tracks Two and Three, the Next Generation Accountable Care Organization (ACO) Model, the Oncology Care Model Two-Sided Risk Arrangement, the Comprehensive End Stage Renal Disease (ESRD) Care Model, the Comprehensive Primary Care Plus (CPC+) model, and certain sufficient risk contracts including Medicare Advantage. The Advisory Board’s Field Guide to Medicare Payment Innovation provides a brief overview of many of these programs.
ACR’s comments in response to the April 27, 2016 proposed rule.
Reported by Inside Health Policy (subscription service) on September 15, 2016.

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