How Will Your Medical Practice Respond to the MACRA?

The Centers for Medicare and Medicaid Services (CMS) has finalized its plans to implement the sweeping payment reforms called for under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. In addition to repealing the Sustainable Growth Rate (SGR) formula, the MACRA creates the Quality Payment Program that rewards physicians and clinicians for giving better care, not just more care. With 10,000 people entering the Medicare program every day, CMS Acting Administrator Andy Slavitt said that it is essential that Medicare continue to support physicians in delivering high-quality care by focusing on patient outcomes and reducing obstacles that make it harder for physicians to practice good care. CMS says that by changing the way physicians are paid, the Quality Payment Program incentivizes quality and value of care over quantity of services.

Repealing or Replacing ACA No Likely Impact

Despite the Trump administration’s promise to repeal major aspects of the Affordable Care Act, Slavitt says he does not expect any changes or slowdown to implementation of the Quality Payment Program. The MACRA replaces the SGR, which was a deeply flawed reimbursement formula that was largely viewed as bad for patients, bad for physicians, and bad for the Medicare program. Slavitt says that by replacing the SGR, the MACRA puts the Medicare program on more sound footing. In addition, the law passed with very strong bi-partisan support with just three senators and 37 congress members voting against the legislation.

New Pressures on Physicians

Implementation of the MACRA puts new pressure on physicians and the organizations that employ them to document and report performance and quality metrics. The changes called for under the MACRA will have a significant impact on physicians and the hospitals and health systems with which they partner. For example, hospitals that employ physicians directly will likely bear the cost for compliance with the new reporting requirements, as well as be at risk for any payment adjustments. And there may be more pressure on physicians and their employers to participate in alternative payment models, such as accountable care organizations or bundled payment programs, given the financial incentives to do so.

Who is in the Quality Payment Program?

Medicare Part B physicians and clinicians will be subject to the Quality Payment Program if they are in an Advanced APM or if they bill Medicare more than $30,000 per year and care for more than 100 Medicare patients per year. For MIPS, clinicians include:

  • Physician
  • Physician Assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist

The Quality Payment Program

Prior to implementation of the MACRA the Medicare program gathered performance metrics on physicians and other clinicians through a patchwork of programs, including the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program. With the new MACRA law, Congress has streamlined elements of these programs through a framework called the Quality Payment Program.

Participation Details for the Quality Payment Program (QPP)

Most Medicare clinicians will initially participate in the Quality Payment Program through MIPS, which will include components of the existing PQRS, VM, and EHR Incentive Program. As an alternative, CMS has established incentives for clinicians to participate in Advanced Alternative Payment Models (APMs). Under this pathway, providers who take on significant financial risk through entities such as accountable care organizations or bundled payments programs can bypass MIPS and become eligible to receive consistent 5% annual payment increases. At least initially, few physicians will qualify to participate under the Advanced APM path, which requires that Medicare comprise 25% of their payments or that Medicare recipients be 20% of their patients through the APM in order to receive the incentive payment.

Regardless of the path, CMS has set 2017 as the performance period for the first payment adjustment in 2019. Payment adjustments under MIPS will be based on performance on measures and activities in four categories, as summarized below.

MIPS clinicians stand to receive a positive, negative, or neutral payment adjustment of up to 4% in 2019. That percentage increases to 9% in 2022. The positive adjustments will be scaled up or down to achieve budget neutrality, meaning that the maximum positive adjustment could be lower or higher than 4%. In the first five years of the program, CMS has also allocated $500 million in an additional performance bonus that is exempt from budget neutrality to reward exceptional performance. This bonus will provide high performers a gradually increasing adjustment based on their MIPS score that can add up to an additional 10%. In addition, CMS has allocated $20 million per year to small practices to provide technical assistance on MIPS performance criteria or assistance transitioning to an APM.

Options for 2017 Participation

Recognizing that physicians are in various stages of readiness for the new reporting system, CMS has outlined several options for reporting during the first year of the program. The options are:

  1. Don’t Participate. If you don’t submit any 2017 data then you will receive a negative 4% Medicare payment adjustment in 2019.
  2. Submit Something. With this option, as long as you submit some data to the Quality Payment Program you will avoid a negative payment adjustment.
  3. Submit a Partial Year. If you submit 90 days of 2017 data, you may earn a neutral or positive payment adjustment.
  4. Submit a Full Year. If you submit a full year of 2017 data, you may earn a positive payment adjustment.

This blog post excerpts an article in the Q1 2017 Provider Advisor. For additional information, complete the form below to download the entire issue.

April 1, 2021