On April 27, 2016, the U. S. Department of Health and Human Services (“HHS”) issued a Notice of Proposed Rulemaking to implement key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (“MACRA”), bipartisan legislation that replaced the Sustainable Growth Rate (“SGR”) formula with a new approach to paying clinicians under Medicare for the services they provide. MACRA eliminated the SGR formula and replaced it with two tracks of value-based reimbursement under Medicare, Alternative Payment Models (“APMs”) and MIPS.
Under MACRA, eligible practitioners (“EPs” – physicians, physician assistants, nurse practitioners, certified nurse specialists, and certified registered nurse anesthetists) can participate in MIPS or meet requirements to be a qualifying APM participant. EPs in MIPS will receive a positive, negative, or neutral payment adjustment. EPs determined to be qualifying or “Advanced” APMs will be excluded from MIPS and receive a 5% lump sum incentive payment for that year.
The recently issued rules did two important things: (1) identified which APMs will qualify for the 5% lump sum payment and exempt practitioners from MIPS and (2) further described the four-category scoring mechanism under MIPS.
To qualify for the 5% incentive payment under APMs, clinicians must receive enough of their payments or see enough of their patients through Advanced APMs. The participation requirements are specified in statute and increase over time. The rules issued last week identified the APMs that will qualify for bonus payments and exemption from MIPS reporting. They are:
·
Comprehensive
Primary Care Plus (CPC+)
·
Next
Generation ACO
·
Medicare
Shared Savings Program (“MSSP”) Tracks 2 and 3
·
Oncology
Care Model with two-sided risk
·
Comprehensive
ESRD Care (for large dialysis organizations)
The
rule also acknowledged that the Centers for Medicare & Medicaid Services (“CMS”)
will continue to add payment models that qualify to be advanced APMs to the
list. However, several noteworthy programs were not included on the initial list, including any bundled payment
program, the Comprehensive Care for Joint Replacement (“CJR”) initiative, and
Track 1 MSSP Accountable Care Organizations (“ACOs”). Currently, physicians are
participating with about 800 hospitals in the CJR program. Additionally, 95% of
the 434 MSSP ACOs are in Track 1.
Participation in an Advanced APM offers
greater rewards (as well as risks) than participation in MIPS. Under MIPS, the potential
for a payment increase is relatively small and very competitive. In order to
determine whether clinicians meet the requirements for the Advanced APM track,
all clinicians will report through MIPS in the first year. HHS acknowledged in
its press release on the proposed rules that many physicians who participate in
existing APMs will not qualify for the flat 5% annual bonus payment.
The proposed rule also further
delineates how MIPS scores will be calculated in order for physicians to
potentially receive bonus payments under the program. MIPS combines some
features of Medicare’s current quality/pay-for-performance programs (i.e., the Physician
Quality Reporting System, the Value Modifier Program, and the Medicare
Electronic Health Record Incentive Program) into one program based on quality,
resource use, clinical practical improvement activities, and meaningful use. MIPS
allows clinicians to be paid by Medicare for providing high quality, efficient
care through success in four performance categories: cost, quality, clinical practice improvement activities, and advancing care information.
