On Wednesday, April 27, the Centers for Medicare and Medicaid Services (CMS) issued its proposed rule
implementing key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the piece of legislation passed by Congress last year replacing the flawed Sustainable Growth Rate (SGR) physician payment formula. MACRA represents a complete overhaul of the structure of physician payments by Medicare.
Under the proposed rule, a new framework of payment called the “Quality Payment Program” requires physicians to choose one of two paths for reimbursement: the Merit-based Incentive Payment System (MIPS)
or Advanced Alternative Payment Models (APMs
Under MIPS, CMS has essentially consolidated three of its quality programs:
Physician Quality Reporting System (PQRS)
Physician Value-Based Payment Modifier (VM)
Medicare Electronic Health Record (EHR) Incentive Program (a/k/a “Meaningful Use”)
If physicians choose the MIPS path, they will receive a score based on four performance categories:
Quality: 50% of total score in year 1 (replaces PQRS and the quality component of VM)
Advancing Care Information: 25% of total score in year 1 ( replaces “Meaningful Use” of EHRs)
Clinical Practice Improvement Activities: 15% of total score in year 1 (new category)
Cost or Resource Use: 10% of total score in year 1 (replaces the cost component of VM)
Based on their total scores, physicians will receive a positive, negative or neutral payment adjustment to their Medicare payments. The law requires MIPS to be budget neutral. In the first year, the adjustments will be no more than +/-4%. Additional bonuses will be awarded to the highest performers. Performance under MIPS will be measured beginning on January 1, 2017, with payment adjustments based on the 2017 performance occurring in 2019.
If physicians are part of an eligible Advanced APM, they can become a “qualifying participant” and will be exempt from participation in MIPS. “Qualifying participants” would qualify for a 5% Medicare Part B incentive payment. In order to qualify as an Advanced APM, three requirements have been proposed:
The practice must use a certified EHR system;
Payment for covered professional services must be based on measures comparable to those in the MIPS program; and
The APM must be an enhanced medical home or bear more than “nominal risk” for losses.
CMS proposes to publish a list of qualifying Advanced APMs prior to each performance period, beginning no later than January 1, 2017.
The policy staff at AANEM is diligently reviewing all 962 pages of the proposed rule to determine how the changes will affect AANEM members. The proposed rule allows for a 60 day comment period during which time AANEM will be enlisting the help of AANEM member volunteers and working with key stakeholders to draft a comprehensive response.
CMS will publish the final rule in the fall of 2016. AANEM will continue to keep its members informed of key provisions and welcomes any and all input from AANEM members. Please contact firstname.lastname@example.org
with any questions or concerns.