At the end of April, CMS issued its proposed rule for the implementation of MACRA. This came roughly one year after the government ended the SGR formula for determining Medicare payments by signing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) into law. The goal of the new legislation is to reward physicians for quality, rather than volume, and streamline existing programs.
Whether you agree or disagree with its execution, CipherHealth believes its main provisions are here to stay. Here are our 5 key takeaways about MACRA and MIPS:
- We project the performance period will be delayed and many of the requirements will be watered down. The bad news is that CMS proposes to use 2017 as the performance period for the 2019 payment adjustments, but the good news is that interest groups almost always succeed at delaying the implementation of onerous CMS programs. Bob Doherty of the of the American College of Physicians has told reporters that physician interest groups are moving toward asking CMS to start the reporting period on July 1, 2017, rather than January 1. Additionally, if the Meaningful Use requirements for Stages 1 and 2 are any indication, many of the requirements in the proposed rule are likely to be “relaxed” in the release of the final rule, which is targeted for early fall 2016.
- Almost all physician groups are likely to be required to report through the Merit-Based Incentive Payment System (MIPS) the first year of the program. CMS will use this data to determine which providers have met the requirements for the APM track. (Each year, eligible clinicians are allowed to switch between MIPS and APM.) As a reminder, MIPS participants can receive a positive, downward, or neutral payment adjustment to Medicare Part B base rates, starting at +/- 4% in 2019 and growing to +/- 9% in 2022 and later. APM participants can receive a 5% lump sum incentive payment on Part B services.
- The majority of providers will only qualify for the MIPS track. The government has proposed a few tracks for measuring performance and obtaining reimbursement: Merit-Based Incentive Payment System (MIPS) participant, Alternative Payment Model (APM) Qualifying participant, or partial Qualifying Participant. APMs include delivery models such as as MSSP Accountable Care Organizations. However, most physician groups are unlikely to meet the proposed nominal risk thresholds. (~95% of MSSP ACOs are participating in Track 1 of the program, which would not qualify them for an exemption from MIPS, as the proposed APM requirements only apply to Track 2 or 3.) That said, the nominal risk thresholds may be less stringent in the final rule.
- Quality is the most important category. MIPS adjusts Medicare Part B reimbursement based on a total composite score derived from four separate categories: quality care, cost-of-care/resource use, clinical practice improvement activities and the “advancing care information” program a.k.a. a modified Meaningful Use program. The quality composite score is weighted at 50% of the MIPS composite score the first year, declining to 30% by the third year, while all the other categories as proposed will be weighted at 10-25% until year 3, when cost/resource use is also weighted at 30% of the total composite score.
- Quality measures will be selected annually through a call for quality measures process, and are likely to include metrics similar to those of PQRS. MACRA identifies five quality domains (i.e., clinical care; safety; care coordination; patient and caregiver experience; population health and prevention). Eligible clinicians would choose to report 6 quality measures compared to the 9 measures currently required under PQRS. CMS indicates there will be more than 200 measures to pick from and over 80% of the quality measures proposed are tailored for specialists. In the recently-released final Quality Measure Development Plan, CMS prioritized the patient perspective with emphasis on patient-reported outcome measures (PROMs) and patient-reported tools, which could include PHQ-9 for depression. The government is also considering ways to make CAHPS surveys easier to administer for patient experience measurement.
The new requirements under MACRA are quite convoluted, and the details are unlikely to be fine-tuned until the release of the final rule later this year. The proposed rule was 962 pages and the Final Quality Measure Development Plan features 80 pages alone on the Quality Domain, for which no actual final measures are provided. However, for those who desire to read the fine print, the proposed rule is available here and the Final MDP is available here.
For more information about how you can prepare for MACRA, contact us today.