In his column May 6, 2016, WHA President/CEO Eric Borgerding described why the implementation of MACRA is a high priority for WHA. MACRA—the Medicare Access and CHIP Reauthorization Act of 2015—combines and streamlines several existing Medicare physician payment systems including the Physician Quality Reporting System (PQRS), the Value Modifier Program and the Medicare Electronic Health Record Incentive Program. The existing programs are being consolidated into a choice of one of two new systems: MIPS—the Merit-Based Incentive Payment System, and APMs—Alternative Payment Models.
The implementation of MIPS and APMs will have a significant impact, not only on physicians, but also on the hospitals and health systems with whom they partner. Hospitals that employ physicians directly may bear some cost from the implementation of and ongoing compliance with the new physician performance reporting requirements, as well as be at risk for any payment adjustments. Hospitals that contract separately with physicians may be called upon to participate in APMs so the physicians with whom they partner can qualify for the APM track.
Performance in the MIPS and APM programs will be used to adjust Medicare payments. The budget-neutral program calls for maximum reduction in payments from 4 percent in 2019 to a maximum of 9 percent in 2022 and after. Providers that demonstrate high performance will receive increases in reimbursement, up to a maximum of 14.5 percent in 2019 and increasing to 19 percent in 2022. The following table summarizes the reimbursement adjustments for 2019 through 2026. Providers who participate in an approved APM will receive an automatic 5 percent bonus.
| Program |
2019 |
2020 |
2021 |
2022 |
2023 |
2024 |
2025 |
2026 |
| Annual Payment Update |
+0.5% |
0% |
0% |
0% |
0% |
0% |
0% |
APM: 0.75%
Others: 0.25% |
| MIPS at-risk payment |
+/- 4% |
+/- 5% |
+/- 7% |
+/- 9% |
+/- 9% |
+/- 9% |
+/- 9% |
+/- 9% |
| MIPS bonus |
< 10% |
< 10% |
< 10% |
< 10% |
< 10% |
< 10% |
|
|
| APM (bonus) |
+ 5% |
+ 5% |
+ 5% |
+ 5% |
+ 5% |
+ 5% |
|
|
| Maximum Potential Increase |
MIPS: 14.5%
APM: 5.5% |
MIPS: 15%
APM: 5% |
MIPS: 17%
APM: 5% |
MIPS: 19%
APM: 5% |
MIPS: 19%
APM: 5% |
MIPS: 19%
APM: 5% |
MIPS: 9%
APM: 0% |
MIPS: 9.25%
APM: 0.75% |
| Maximum Potential Reduction |
MIPS: 4%
APM: 0% |
MIPS: 5%
APM: 0% |
MIPS: 7%
APM: 0% |
MIPS: 9%
APM: 0% |
MIPS: 9%
APM: 0% |
MIPS: 9%
APM: 0% |
MIPS: 9%
APM: 0% |
MIPS: 9%
APM: 0% |
Source: American Hospital Association
CMS Releases Proposed Rule
A proposed rule released by the Centers for Medicare & Medicaid Services (CMS) April 28 includes provisions for the MIPS and APM components of MACRA. MIPS will apply to physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists, including those who bill under Critical Access Hospital Method II billing.
The MIPS portion replaces the existing PQRS and calls for providers to report on six quality measures. Providers will also be required to report Clinical Practice Improvement Activities (CPIAs), choosing from a list of 90 options. The program also includes cost measures, which will be calculated by CMS using Medicare claims. Finally, MIPS includes a component called “Advancing Care Information,” which will replace the existing Medicare meaningful use program.
Clinicians who are enrolled in a CMS-approved APM will be exempt from participation in MIPS. An eligible APM entity must bear financial risk for monetary loss (more than nominal amount) or be a primary care medical home. An eligible APM must require use of certified electronic health record (EHR) technology and provide payment based on quality measures comparable to those in the MIPS quality category.
The initial six APM models that are proposed in the rule are: Comprehensive Primary Care Plus (CPC+); Medicare Shared Savings-Track 2; Medicare Shared Savings-Track 3; the Next Generation ACO Model; Comprehensive End-Stage Renal Diseases Care Model; and the Oncology Care Model Two-Sided Risk Arrangement.
The proposed rule also details some of the work of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to review and assess additional physician-focused payment models suggested by stakeholders. Jeff Bailet, MD, president, Aurora Health Care Medical Group, chairs this new advisory committee.
WHA Engagement
WHA’s goal is to ensure members have the information and tools they need to participate in MIPS and APMs, as necessary and/or to decide their level of engagement. As with any important initiative of this kind, WHA will stay on top of federal rules and regulations, submitting comments on behalf of our members to help improve the policy direction as needed. The work of MACRA may evolve to include legal, reimbursement, data and other issues that will be addressed by WHA’s staff and existing councils.
WHA is fortunate to have a team of physician leaders working with us through our Physician Leaders Council, and we will work with those physician leaders to help guide our policy, education and communication efforts. The Council had preliminary discussion on the proposed rules at its meeting May 18. Council members will be providing feedback to WHA staff in the coming month, which will be incorporated into formal comments to CMS. WHA is also fortunate to have Dr. Bailet as chair of the PTAC, and we look forward to working with him.
WHA will also continue to develop its new subsidiary, Physician Compass, created as a joint venture with the Wisconsin Collaborative for Healthcare Quality, to position itself to be a quality improvement resource and reporting vehicle for physicians, both employed and independent, in the new MACRA world.
As WHA rolls out its MACRA activities, watch for a series of webinars later in 2016, which will cover the basic information members need to know about MIPS and APMs, and to address the elements that hospitals and physicians should consider preparing to be ready for these programs.
The new MACRA program will affect all providers and health systems to a varying degree, making it important to understand the program and determine the appropriate way to participate. WHA members can provide input to Joanne Alig, WHA senior vice president, at
jalig@wha.org or Kelly Court, WHA chief quality officer, at
kcourt@wha.org.