How Familiar Are You With MACRA?

How Familiar Are You With MACRA?

An Overview on the MACRA- Medicare Access and CHIP Reauthorization Act of 2015

The MACRA- Medicare Access and CHIP Reauthorization Act of 2015, also known as MACRA, was signed in by the President on April 14, 2015. It promises to change the way the United States pays for and evaluates healthcare.

Rising costs of healthcare and a long history of unnecessary issues are being addressed through this new program. This is intended to be a win for both physicians and the consumer. Physicians will have clear guidelines as to how they will be evaluated and have opportunities to make additional money based on performance and consumers will be able to have more of a choice in the say of their healthcare. The outcome of this initiative should result in consumers having clear comparative information on health plans, provider options, treatment options and their total cost of care. MACRA is designed to save clinicians time spent on reporting of quality measures.

In short, MACRA is intended to incentivize clinicians to address the problems that have long plagued our health system:

  • 25-30% rate of unnecessary, inappropriate or excessive care
  • Misdiagnosis and medical errors
  • High and escalating prices and an unsustainable cost growth trend
  • The most expensive health care system in the world even as it yields poorer overall results compared to other developed nations that spend less

Currently, physicians have a substantiated concern that the burden of measurement today is excessive. Financial incentives will drive physicians to improve performance. By 2022, the majority of doctors will either have 30-50% of their income tied to performance or receive a salary in an integrated system. Financial incentives are a definite motivator and have proven successful in other areas.

There are two payment tracks for physicians to choose from. The default one is called the Merit-based Incentive Payment System or MIPS. The other is the voluntary track and it is available to those who participate in certain “advanced” Medicare alternative payment models (APMs) and their performance within the track selected. It is anticipated that most ophthalmologists will participate in the MIPS program.

This Quality Payment Program will tie Medicare Part B payments to performance and all participants will fall under one of two tracks, MIPS and APMs.

MIPS: Under this model, Medicare Part B payments can be adjusted up or down based on performance. MIPS will be mandatory and apply to all practices that are not exempt from participating in an advanced APM.

MIPS combines certain elements of the three current Medicare fee-for-service physician quality programs. According to CMS, the goal in developing MIPS is to advance a program that is meaningful, understandable and flexible for clinicians that participate.

  1. Physician Quality Reporting System (PQRS)
  2. Value-Based Payment Modifier (VM)
  3. Meaningful Use Electronic Health Record (HER) Incentive Program

Physicians will receive a composite score each performance period that will be compared to a performance threshold that is determined ahead of time. They will receive a positive or negative adjustment based on whether their score falls above or below the performance threshold. In 2019, the MIPS adjustment will begin at plus or minus 4% and gradually increase to plus or minus 9% in 2022 and moving forward. If you are considered an “exceptional” performer, you will be eligible for an extra bonus. Eligible clinicians will have the option of having their performance evaluated individually or as part of a group. An estimated 687,000-746,000 eligible clinicians would have their Medicate payment adjusted under MIPS in 2019.

Who will be subject to Medicare Part B adjustments under MIPS?

If you are a clinician that currently bills for Part B services under the PFS and are a physician, physician assistant, nurse practitioner, clinical nurse specialist or certified registered nurse anesthetists then MIPS would apply. Excluded categories include:

  • New Medicare-enrolled eligible clinicians
  • Qualifying APM participants (QPs) and partial qualifying APM participants (Partial QPs)
  • Other eligible clinicians who treat a low-volume of Medicare beneficiaries.

Clinicians that fall under the MIPS umbrella will be evaluated using the following:

  • Quality- 50%
  • Resource Use- 10%
  • CPI Activities- 15%
  • Advancing Care Information2 25%

MACRA requires CMS to evaluate MIPS clinicians utilizing those four performance categories.

Advanced APMs: If physicians participate in an “Advanced APM” like risk-bearing Accountable Care Organizations (ACOs), they are eligible for a separate incentive which is a 5% bonus on Part B payments. They are also exempt from MIPS payment adjustments. The Centers for Medicare and Medicaid Services (CMS) define these providers that qualify for the 5% bonus as “qualifying APM participants” or “QPs”. While the option to participate in an advanced APM is indeed real, CMS predicts that most clinicians will be subject to MIPS by default. In addition, even though participants are in an APM, they still may not meet certain thresholds set up by CMS to qualify for the bonus.

When will implementation of these things begin?

2019 will be the first “payment year” for the Quality Payment Program. This is when MIPS payment adjustments will start to make an impact on Part B payments for practices eligible for MIPS and the 5% bonus for APM participants will be payable. It’s important that physicians review their performance now before January 1, 2017 as 2019 payments will be based on 2017 performance. The Quality and Resource Use Reports (QRURs) will outline the practice’s performance using the current physician value-based (VM) payment modifier program. In addition, to determine if a clinician is a participant in Advanced APM, CMS will review the performance period two years prior to the bonus being payable. If you are not participating in an advanced APM in 2017, you will not be eligible for the 2019 bonus.

While there is a lot of information tied to MACRA, getting a clear understanding now will prepare you for the first incentive pay year in 2019. If you have questions or would like help, contact us today!