Medicare Access & CHIP Reauthorization Act Preparation Tips

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 MACRA repealed the Medicare Sustainable Growth Rate (SGR) methodology for updates to the Physician Fee Schedule (PFS) and replaced it with a value-driven payment system.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:

1. Support care improvement by focusing on better outcomes for patients, decreased provider burden and preservation of independent clinical practice;
2. Promote adoption of APMs that align incentives across healthcare stakeholders; and
3. 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:

1. Quality (2017) (replacing the Physician Quality Reporting System [PQRS]);
2. Advancing Care Information (2017) (replacing the Medicare Electronic Health Record [EHR] Incentive Program, also known as Meaningful Use);
3. Clinical Practice Improvement (2017) (new category); and
4. 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.

Clinicians who enroll in Medicare for the first time during a performance period are exempt from reporting on measures and activities for MIPS until the following performance year. In addition, any clinicians who fall below the low-volume threshold (i.e., have Medicare Part B allowed charges less than or equal to $30,000 or who have 100 or fewer Medicare Part B patients) are also exempted. Finally, clinicians who significantly participate in advanced APMs are exempt.

When

The implementation of MACRA has been a long process, commencing with its passage in April 2015. On Oct. 14, 2016, the CMS announced the final regulations and offered physicians the option to “pick their pace” for participating in QPP during the transition year, which commenced Jan. 1, 2017. The first option was a test pace, pursuant to which physicians submit some reportable data after Jan. 1, 2017. Physicians who chose this route were deemed eligible for a neutral or small payment adjustment.

The second option was partial-year participation, in which physicians would report for a continuous 90-day period after Jan. 1, 2017. In return, these physicians would receive a small positive payment adjustment.

The final option was full-year participation, pursuant to which physicians would fully participate starting Jan. 1, 2017. These physicians would receive a modest positive payment adjustment in return.

It is worth noting that physicians who refused to participate in the QPP for the transition year will receive a negative 4% payment adjustment.

On Dec. 31, 2017, the first performance period closed for all providers, and performance data must be submitted to the CMS by March 31, 2018. The CMS intends to provide feedback on the data received.

On June 20, 2017, the CMS released its proposed rule updating the QPP for CY 2018. That rule proposed an expansion and extension of the flexibility offered to practitioners in the 2017 performance period into the 2018 performance period. The proposed rule would expand the group of practitioners in the low-volume threshold from under $30,000 in Medicare Part B charges or less than 100 Medicare Part B patients to under $90,000 in Medicare Part B charges or less than 200 Medicare Part B patients. In addition, the proposed rule would continue a modified version of the “pick your pace” approach to MIPS-participating clinicians.

On Nov. 2, 2017, the CMS issued the final rule for CY 2018. The final rule includes policies to reduce the administrative burden placed on providers by clarifying the details on many aspects of the program, including the APM scoring standard. In addition, CMS is decreasing the number of clinicians required to participate in QPP. There is also a new hardship exception to assist small practices and clinicians affected by natural disasters, such as Hurricanes Harvey, Irma and Maria. Finally, the final rule included the flexibilities that were in the proposed rule.

What Do I Do Now?

Although the QPP program for CY 2018 grants continued flexibility to program participants, the program is still expected to commence as initially planned in 2019. Therefore, reporting providers should spend time now carefully evaluating their practices and improving their performance in the MIPS measurement areas. Recommended tips include the following:

1. Review the CMS’s list of proposed quality improvement activities and determine whether your practice and patients would benefit from implementation of any additional strategies.
2. Review prior PQRS performance measures, and determine your practice’s weaknesses. Invest time now correcting those weaknesses and improving your practice’s strengths.
3. If you will be seeking scoring as a virtual group under MIPS, begin preparing for this possibility by preparing a formal written agreement between each member of the virtual group. Virtual groups can comprise solo practitioners and groups of 10 or fewer eligible clinicians who come together virtually to participate in MIPS for a performance period. Certain rules and definitions apply.
4. If you have not done so already, consider updating your practice’s EHR to a platform that is considered 2015 Certified Electronic Health Record Technology.

QPP is an extremely detailed program and can be an administrative nightmare if you do not begin preparations now. Maximize your chances of positive payment adjustments and begin preparing now.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC. Contact him via email at [email protected].