As part of its ongoing effort to transition to value-based reimbursement, the Centers for Medicare & Medicaid Services (CMS) secured approval for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which will significantly affect physicians and medical practices. This legislation repealed the Sustainable Growth Rate methodology (replacing it with annual 0.5% rate increases until 2019) and introduced a two-part Quality Payment Program (QPP).
The QPP includes the Merit-Based Incentive Payment System (MIPS), which offers incentives and assesses penalties based on performance in four categories, and Advanced Alternative Payment Models (APMs). While the following is not an exhaustive analysis, The Academy has reviewed and summarized key proposals for implementing MIPS, which is expected to apply to more providers than APMs.
Identifying Eligible Clinicians
CMS issued a notice of proposed rule-making in April 2016 to implement and further define the QPP. According to the proposed rule, MIPS would apply to certain “eligible clinicians”—physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists—participating either individually or in groups. MIPS would exclude any otherwise eligible clinicians who have been enrolled as Medicare providers for less than a year, who participate in APMs, or who fall below a low-volume threshold (i.e., treat no more than 100 Part B beneficiaries and bill Medicare for no more than $10,000 annually). According to the proposed rule, CMS expects MIPS to affect between 687,000 and 746,000 eligible clinicians in 2019, the program’s first year in effect.
Under MACRA, payment adjustments under the Physician Quality Reporting System, the Physician Value-Based Payment Modifier, and EHR Meaningful Use programs would be discontinued at the end of 2018, and certain provisions would be consolidated in MIPS. Eligible clinicians would receive an annual MIPS composite score based on performance in quality measures (accounting for 50% of the score in 2019), resource use (10%), clinical practice improvement activities (15%), and EHR Meaningful Use (25%). Based on performance, they would receive positive, negative, or neutral adjustments.
Navigating Quality Measures
Most eligible clinicians would be held to at least six quality measures during each performance period, though selections could vary from one period to the next and are expected to cover various topics, including the patient experience, outcomes, and patient safety, among others. CMS has proposed reconsidering the list of acceptable measures annually and publishing an update each November 1st. Resource use would be determined by considering an eligible clinician’s total per capita costs for all attributed beneficiaries, as defined in the rule, and Medicare Spending Per Beneficiary data, with some adjustments. Eligible clinicians reporting individually would also be evaluated based on some episode-based measures, such as for specific types of high-cost care, among other factors. In the proposed rule, CMS states that it plans to provide specific feedback on performance in these two categories. Clinical practice improvement activities would include multiple initiatives, such as care coordination, population management, and similar efforts. The central tenets of EHR Meaningful Use, reframed as “advancing care information,” would continue under MIPS and would emphasize system connectivity, among other factors.
Realizing Incentives or Adjustments
Composite scores would range up to 100 points, and eligible clinicians would be evaluated against performance benchmarks set by CMS. According to the proposed rule, 2017 will be the performance period for 2019 benchmarks. During MIPS’ first year, adjustments are not expected to exceed 4% of an eligible clinician’s Medicare Part B reimbursement (increasing gradually to 9% by 2022), though participants will be given credit for partial performance, meaning actual incentives or recoupments could be less than 4%. According to the proposed rule, CMS expects positive and negative adjustments (totaling $833 million in 2019) to offset, maintaining budget neutrality. However, it also proposes budgeting $500 million for “exceptional performance” bonus incentives to be awarded in the first five years of MIPS. Finally, CMS proposes publicizing eligible clinicians’ attainment through its Physician Compare Initiative website.
Public comments were due by June 27th, so the final provisions of MIPS could vary. However, as CMS continues to shift to value-based reimbursement, revenue cycle leaders could benefit from determining how MIPS could affect them. By preparing staff, leaders could position themselves to adapt with minimal difficulty while continuing to provide high-quality care to patients.