The Centers for Medicare and Medicaid Services (CMS) has unveiled a proposal that would carry out a major overhaul of its payments for physicians. The proposed rules, released on April 27, stem from a mandate included in last year’s passage of the Medicare Access and CHIP Reauthorization Act (MACRA), federal legislation that repealed the Medicare sustainable growth rate formula (SGR).
MACRA puts in place a new reimbursement framework called the Quality Payment Program (QPP). The QPP consists of two tracks: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM). All eligible clinicians will report through MIPS during the first year of the program – calendar year 2017. After the collection of the first year’s data, CMS will determine which providers meet the requirements for the APM track. Those physicians will have the option to choose between the MIPS and APM tracks annually.
Under the proposed rule, eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse practitioners, certified nurse anesthetists, and groups that include such physicians. Exempted will be Medicare newly enrolled (first year) clinicians and clinicians below the low-volume threshold. MIPS will not apply to hospitals or facilities and clinicians providing services in Rural Health Clinics, and Federally Qualified Health Clinics will be required to participate in MIPS if they provide services under the Physicians Fee Schedule.
Though the performance measurement period begins in 2017, the new payment system, if approved as proposed, takes effect in 2019. MIPS will combine the existing Physicians Quality Reporting System (PQRS), the Valued-based Modifier, and the Electronic Health Records Incentive (Meaningful Use) programs. The consolidation of programs aims to streamline the process that will measure the quality and efficiency of care delivered.
Starting January 1, 2017, and running through December 31, 2017, the MIPS reporting path will consist of physicians being evaluated and scored in four performance categories:
- Quality (50 percent of total score in 2017). Clinicians will choose six measures, from a list of 200, to report based on those that best reflect their practice and outcome measurements.
- Advance Care Information (25 percent of total score in 2017). Clinicians will choose to report on customizable measures (which will be reduced from 18 to 11) that reflect the use technology in their day-to-day practice with an emphasis on interoperability and information exchange.
- Clinical Practice Improvement Activities (15 percent of total score in 2017). This category would reward clinical practice improvements that focus on areas such as care coordination, beneficiary engagement, and patient safety. Clinicians will be able to select from more than 90 options to best match their practice’s goals.
- Cost (10 percent of total score in 2017). In this last category, a score will be based on Medicare claims, meaning no reporting requirements for clinicians. The category will use 40 episode-specific measures to account for differences among specialties.
The Advanced APM path is for clinicians who meet certain thresholds on patient contact or who receive enough of their payments through Advanced APM models, such as the Medicare Shared Savings Program (Tracks 2 or 3), Comprehensive Primary Care Plus, the Comprehensive End Stage Renal Disease (ESRD) care model, and the Next Generation Accountable Care Organization (ACO) model. In general, these models require participants to bear a certain amount of financial risk, base payments on quality measures similar to those under MIPS, and require use of certified electronic health record technology. Medical home models also qualify as Advance APMs regardless of whether they meet the financial risk requirement. After 2017, CMS will determine which MIPS clinicians can further qualify to participate in an Advance APM. These physicians will be exempt from MIPS, but may nonetheless choose to operate under the MIPS model.
The deadline to submit a comment on the proposed regulations is June 27, 2016. CMS must release the final regulations by November 1, 2016.