Breakdown of the MACRA Proposed Final Rule
Last week, the Centers for Medicare and Medicaid Services (CMS) began the process of implementing the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) by releasing its proposed final rule.
Currently, Medicare measures the value and quality of care provided by doctors and other clinicians through a patchwork of programs. For example, some providers are part of Alternative Payment Models (e.g., Accountable Care Organizations, the Comprehensive Primary Care Initiative, the Medicare Shared Savings Program). Most also participate in programs like the Physician Quality Reporting System, the Value Modifier Program and the Medicare EHR Incentive Program.
These programs have now been streamlined into a single framework to help clinicians transition from payments based on volume to payments based on value.
MACRA will eliminate the sustainable growth formula and replace it with a .5% annual rate increase through 2019, after which physicians are encouraged to shift to one of two Quality Payment Programs: 1) Merit-Based Incentive Payment System (MIPS) or 2): Alternative Payment Model (APM).
Most Medicare providers will initially participate in the MIPS program, which will combine three existing programs – the Physician Quality Reporting System, the Value-Based Modifier Program (VBMP) and Meaningful Use of EHRs – into one program.
Clinicians will be paid based on four performance categories:
- Quality: This category replaces the Physician Quality Reporting System. Providers will choose six measures to report on from a range of options that take into account specialty and practices.
- Advancing Care Information: This is the category that replaces Meaningful Use. Providers can choose customizable measures to report on 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: This category would reward clinical practice improvements (e.g., activities focused on care coordination, beneficiary engagement, patient safety). Providers can choose activities that match their goals from more than 90 options.
- Cost: This category replaces the VBMP. Scores will be calculated based on Medicare claims, which means there will be no reporting requirements for providers. This category includes 40 episode-specific measures that account for differences among specialties.
An APM is a Center for Medicare & Medicaid Innovation payment model under section 1115A. Examples include Accountable Care Organizations, Patient Centered Medical Homes (PCMH) and bundled payment models.
To meet eligibility requirements, APMs must:
- Use certified EHRs;
- Pay providers based on quality measures comparable to those under MIPS; and
- Assume more than a “nominal risk” for financial losses OR be an accredited PCMH.
Providers participating in a qualified APM will get a 5% bonus from 2019 to 2024.
Initial feedback from the field
As with most proposed rules, initial feedback has been mixed. “Our initial review suggests that CMS has been listening to physicians' concerns,” Steven J. Stack, M.D., President of the American Medical Association said in a statement. “In particular, it appears that CMS has made significant improvements by recasting the EHR Meaningful Use program and by reducing quality reporting burdens.”
Comments from Tom Nickels, executive vice president of the American Hospital Association, were not so positive. “We are disappointed by CMS’s narrow definition of alternative payment models, which could have a chilling effect on providers’ ability to experiment with new patient-centered, value-driven payment models,” Nickels said in a press release. “Today’s rule fails to recognize the significant resources and risk assumed by the highly motivated, early adopters of alternative payment models.”
Blair Childs, senior vice president of public affairs at Premier Inc., was also not pleased with the proposed final rule. Childs told Healthcare IT News that CMS "made a significant mistake in not including any bundled payment or Track 1 Medicare Shared Savings Program ACOs as qualifying advanced payment models under MACRA."
“Rather than rejecting bundled payment programs, we believe CMS should focus on ways to alter the bundled payment programs to demonstrate use of certified EHR technology and align measures with other Advanced APMs.”
CMS will be accepting comments on the proposed rule until June 27.