The ABCs of MACRA
The transition year under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is at an end. MACRA repealed the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule (PFS) and replaced it with a value-driven payment system. The new approach to payment is called the Quality Payment Program (QPP).
Beginning in 2019, MACRA will reward the delivery of high-quality patient care two ways: 1) through Advanced Alternative Payment Models (Advanced APMs), and 2) through the Merit-Based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS.
The Centers for Medicare & Medicaid Services (CMS) stated that the aim of the QPP is to:
- Support care improvement by focusing on better outcomes for patients, decreased provider burden and preservation of independent clinical practice;
- Promote adoption of APMs that align incentives across healthcare stakeholders; and
- Advance existing efforts of delivery system reform, including ensuring a smooth transition to a new system that promotes high-quality, efficient care through unification of CMS legacy programs.
The ultimate goal of MACRA is to reward providers for better, lower-cost, patient-centered care. This is yet another example of the CMS moving away from fee-for-service payments and, instead, embracing APMs. The goal of the CMS is to have 50% of Medicare payments be made through APMs, and have 90% of remaining fee-for-service payments tied to quality and value by the end of 2018.
Advanced APMs
The advanced APM avenue enables physicians to participate in the QPP through APMs. APMs include certain payment approaches that offer added incentive payments in exchange for the provision of high-quality and cost-efficient care, such as shared savings programs, patient-centered medical homes and bundled payment models.
[Editor’s note: The ACR is developing a rheumatology-specific APM, and details will be published as they are available. See https://www.the-rheumatologist.org/article/acr-exploring-rheumatology-specific-apm and https://www.the-rheumatologist.org/article/ama-workshop-focuses-alternative-payment-models.]
MIPS
MIPS allows clinicians participating in Medicare Part B to earn a performance-based payment adjustment to their Medicare reimbursement based on individual performance in four main categories:
- Quality (2017) (replacing the Physician Quality Reporting System [PQRS]);
- Advancing Care Information (2017) (replacing the Medicare Electronic Health Record [EHR] Incentive Program, also known as Meaningful Use);
- Clinical Practice Improvement (2017) (new category); and
- Cost (2018) (replacing the Physician Value-Based Modifier Program [PM]).
Medicare Part B clinicians who bill more than $30,000 per year and provide care for more than 100 Medicare patients per year must participate in MIPS. Such clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.