On April 16, 2015, President Obama signed into law H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a law that repealed the Sustainable Growth Rate (SGR) formula for Medicare physician payment, whose problematic history has plagued Medicare physician payment issues for over a decade.
As such, MACRA has created new options for Medicare physician payment. Beginning in 2019, physicians may choose between the new Merit-based Incentive Payment System (MIPS) or participate in a qualifying alternative payment model (APM). A physician that is a qualifying participant of an APM (meaning the physician receives 25 percent of payments through services furnished through a qualifying APM in 2019 or 2020; 50 percent of payments in 2021 and 2022; and 75 percent of payments in 2023 and beyond) will not need to participate in the MIPS and will receive a 5 percent bonus to its estimated aggregate payments for covered professional services, according to the law.
Also noteworthy is that starting in 2017, MIPS will combine several existing programs, including the meaningful use program, the Physician Quality Reporting System (PQRS) and the Value-Based Payment Modifier (VBM). It will measure Medicare Part B providers in four performance categories to derive a score (0 to 100) that could impact a provider’s Medicare reimbursement positively or negatively starting at 4 percent in 2019 and gradually increasing to 9 percent for 2022. Specifically, according to a College of Healthcare Information Management Executives (CHIME) summary of the health IT provisions of the law, to implement the MIPS, MACRA directs the Centers for Medicare & Medicaid Services (CMS) to assess physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists (“MIPS Eligible Professionals” or “MIPS EPs”) on four performance categories: 1) Quality; 2) Resource use; 3) Clinical practice improvement activities; and 4) Meaningful use of certified electronic health record (EHR) technology.
What’s more, according to a Quality Measure Development Plan (MDP) released by CMS late in 2015, MACRA identifies five quality domains (i.e., clinical care, safety, care coordination, patient and caregiver experience, population health and prevention) for measures developed under the MDP, which aims to serve as a strategic framework for the future of clinician quality measure development. CMS is required to enter into contracts for the purpose of developing, improving, updating, or expanding its measure development plan, and must publish an annual report with progress made during each year, including a listing of the new measures developed. MACRA provides CMS $15 million each year from 2015-2019 to accomplish these tasks, according to the CHIME summary.
Still, nearly a year after the bill was signed into law, physician leaders find themselves in quite the precarious position—even as the first program year of the law is scheduled to start in less than 12 months, there is little awareness about the health IT provisions of MACRA amongst the provider community; CMS is expected to release a proposed rule this spring and a final rule later in the summer. As such, Leslie Kriegstein, vice president of Congressional Affairs at the Ann Arbor, Mich.-based CHIME, says there is substantial confusion throughout the industry regarding the bill’s implications.
“This is a fundamental payment overhaul,” Kriegstein attests. “Folks are pointing to 2019, but that’s the first payment year. As things stand today, we are rapidly approaching the first program year of 2017. There is no rulemaking yet, and it’s still going to be a very expedited timeframe by the time we respond to those proposals and see them finalized. Folks will have to put the pedal to the metal after that.”
Right now, Kriegstein adds, “We need re-education to bring folks back to reality. Who exactly who is eligible for any programmatic changes made via MACRA, and also, what’s within CMS’ ability, and what’s dug into statute? We’re waiting to see how CMS interprets the statutory authority that Congress gave them last year,” she says.
Tom Lee, Ph.D., founder and CEO of Chicago-based consulting and software firm SA Ignite, agrees that physician leaders need to become quickly educated about the legislation, if they are not already. First, Lee asks, what are the top-to-bottom financial impacts in dollars and percentage payment adjustments that MIPS could mean for an organization? He notes that it could be as much as a 36 percent financial impact on an organization’s Medicare Part B, “which is 10 times greater than any other program ever was.” Lee adds, “You have to get more educated. Given the short time window we have, if when the rule comes out is the first time you learn about MIPS, you will have very little opportunity to do anything. The learning curve is so steep.”
Tom Lee, Ph.D.