More than a year has passed since Congress voted to enact the Medicare Access and CHIP Reauthorization Act of 2015 and the Department of Health & Human Services issued its notice of proposed rulemaking for MACRA implementation.
At its most basic, MACRA repeals the sustainable growth rate — a series of Congressional fixes responsible for adjusting Medicare expenditures and provider reimbursement — and authorizes HHS to implement value-based initiatives aimed at improving care access for Medicare and CHIP beneficiaries. But MACRA is much more than that.
Chief among the major provisions of the MACRA proposed rule is the Quality Payment Program, which aims to streamline various quality reporting programs under a single one. The new program comprises one of two paths for (at the moment) eligible clinicians: the Merit-based Incentive Payment System (MIPs) and Alternative Payment Models (APMs).
What is the Quality Payment Program?
Simply put, the Quality Payment Program is HHS's take on further transitioning the healthcare industry from fee-for-service to value-based care.
“In implementing the new law, we were guided by the same principles underlying the bipartisan legislation itself: streamlining and strengthening value and quality-based payments for all physicians; rewarding participation in Advanced APMs that create the strongest incentives for high-quality, coordinated, and efficient care; and giving doctors and other clinicians flexibility regarding how they participate in the new payment system,” a Centers for Medicare & Medicaid Services (CMS) fact sheet states.
Under the Quality Payment Program, Medicare physicians, physician assistants, and nurses must participate in either MIPs or APMs to receive a positive, neutral, or negative Medicare payment adjustment in subsequent years.
MIPS takes the place of the EHR Incentive Programs, Physician Quality Reporting System, and Value Modifier Program; meanwhile, various accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) are the means for qualifying as an Advance APM (more on this later).
- How Value-Based Care Looks Under the Quality Payment Program
- MACRA Quality Payment Program Promotes Alternative Payment Models
What is the Merit-based Incentive Payment System?
MIPS comprises four performance categories used to score a MIPS-eligible clinician's quality, use of services, EHR use, and quality improvements to care coordination and delivery:
- Quality (50%)
- Resource use (10%)
- Advancing care information (25%)
- Clinical practice improvement activities (15%)
Whether a MIPS-eligible clinician's composite performance score exceeds, meets, or falls short of the threshold set by CMS determines a positive, neutral, or negative payment adjustment in later years. Beginning in 2019, the payment adjustment is four percent, following five percent in 2020, seven percent in 2021, and nine percent in 2022 and beyond.
Meeting requirements for the quality performance category requires MIPS-eligible clinicians to successfully report on six clinical quality measures over a 12-month performance period.
For resource use, CMS will use the total per capita cost measure, the Medicare Spending per Beneficiary (MSPB) measure, and several episode-based measures to assess the amount of services MIPS-eligible clinicians provide during a full performance period.
Advancing care information is the replacement for meaningful use. Scoring for this performance category comprises a base score for fulfilling the requirements for six objectives and measures (50 points).
Next is the performance score (80 points) for which MIPS-eligible clinicians must select "measures that best fit their practices" from three categories of objectives: patient electronic access, coordination of care through patient engagement, and health information exchange.
These clinicians become eligible for a bonus point if they report to immunization registries or other public health registries.
MIPS-eligible clinicians must achieve a total score of more than 100 points to receive the full 25 percent for advancing care information under MIPs.
For the clinical practice improvement activities (CPIAs) performance category, MIPS-eligible clinicians must choose a pre-determined number of options from a list of 90 to prove that they have focus on care coordination, beneficiary engagement, and patient safety.
The MACRA proposed rule includes provisions aimed at supporting critical access hospitals and federally qualified health centers, which won’t face the pressure to gain a high a MIPS score because they won’t be required to.
CMS has also proposed that services provided at Critical Access Hospitals, Rural Health Clinics and Federally Qualified Health Centers that meet certain criteria “be counted towards the Qualifying APM Professional determination.”
Although many providers (e.g., CAHs) will choose to opt out of MIPS and other programs due to a lack of patients and resources, those providers will also miss out on opportunities to reap rewards from the system.
HHS will encourage exempt providers to contribute data on MIPS performance measures even though they are not participating in the program as a way to collect better data on systemic performance and help them become more familiar with the MIPS ecosystem.
- MIPS Requirements for Physicians Under Proposed MACRA Rule
- Understanding MIPS Eligibility under Proposed MACRA Rule
- Comparing Advancing Care Information to Meaningful Use
- How MACRA, MIPS Will Impact Critical Access Hospitals, FQHCs
What are Alternative Payment Models?
APMs are risk-based arrangement between providers and payers, with the most common being accountable care organizations such as those in the CMS-run Medicare Shared Saving Program or Next-Generation ACOs.
This path to satisfying the requirements of the Quality Payment Program under MACRA require providers receiving reimbursement mostly through these arrangements to demonstrate that they meet the requirements of Advance APMs:
- Require participants to bear a certain amount of financial risk
- Base payments on quality measures comparable to those used in the MIPS quality performance category
- Require participants to use certified EHR technology.
“As a nation, we’ve made significant advances in transitioning the healthcare system to one that pays for quality, encourages coordinated care and smarter spending, and focuses on better outcomes for people," CMS Acting Administrator Andy Slavitt said during a media call last week. "Accountable care organizations, comprehensive primary care models, and bundled payments are gaining significant traction. The Medicare FFS program now has over 30% of its payments in programs like these, and the number is rising."
Advanced APMs can come in two varieties: Advanced APMs administered by CMS or Other Payer Advanced APMs administered by private payers.
"Accountable care organizations, comprehensive primary care models, and bundled payments are gaining significant traction. The Medicare FFS program now has over 30% of its payments in programs like these, and the number is rising."
According to HHS, the federal agency expects between 30,658 and 90,000 providers to become Qualifying APM Participants in Advanced APMs, and are estimated to receive between $146 million and $429 million in Alternative Payment Model Incentive Payments in 2019.
What MACRA implementation means to patients, population health?
EHR use is at the core of the Quality Payment Program with both MIPS and APMs requiring the use of certified EHR technology to qualify for positive Medicare payment adjustments.
While meaningful use is disappearing as a standalone program, it remains influential in MIPS requirements and the technology necessary to achieve them. Under the MACRA propose rule, EHR technology must meet the 2015 Edition Health IT Certification in coming years, which places strong emphasis on the use of application programming interfaces (APIs) to ensure secondary and tertiary uses of clinical health data.
“Because this proposal is aligned with the 2015 CEHRT, physicians will be using technology with open APIs to allow analytics tools and devices easier connectivity,” Slavitt said. “We urge developers and the technology community to take advantage of the proposed flexible regulations when they’re ultimately finalized so they can design around the everyday needs of users, rather than designing around the one-size-fits-all regulated approach.”
The use of CEHRT and APIs should enable an ecosystem wherein providers can succeed at population health management and emerging analytics-based approaches to care delivery. At the same time, these APIs should allow patient-generated health data to contribute more directly to the complete picture of a patient's health profile.
"These are measures that reflect the potential to improve patient-centered care and the quality of care delivered to patients."
Of all the provisions comprising the MACRA proposed rule, CMS continues to stress that MACRA implementation is first and foremost about patient-centric care.
"These are measures that reflect the potential to improve patient-centered care and the quality of care delivered to patients," the proposed rule states. "They emphasize the importance of collecting patient-reported data and the ability to impact care at the individual patient level, as well as the population level. These are measures of organizational structures or processes that foster both the inclusion of persons and family members as active members of the health care team and collaborative partnerships with health care providers and provider organizations or can be measures of patient-reported experiences and outcomes that reflect greater involvement of patients and families in decision making, self-care, activation, and understanding of their health condition and its effective management."
The patient-centeredness of MACRA will require patient access and exchange of health data through health technologies, which in turn require interoperability to be achieved fully.
- APIs, Population Health Take Central Role in MACRA Implementation
- How MACRA, MIPS will Help Deliver Patient-Centered Care
What is the healthcare industry saying about MACRA implementation?
You can't please all the people all the time. This is especially true in healthcare.
According to the American Hospital Association (AHA) the proposed role is too narrow despite CMS’s efforts to refocus value-based reimbursement programs to align with hospital and provider needs.
“We are disappointed by CMS’s narrow definition of alternative payment models, which could have a chilling effect on providers’ ability to experiment with new patient-centered, value-driven payment models,” explained AHA Executive Vice President Tom Nickels said in an official statement. “Today’s rule fails to recognize the significant resources and risk assumed by the highly motivated, early adopters of alternative payment models.”
The American Medical Association (AMA), meanwhile, sees promise in the MACRA proposed rule.
“Our initial review suggests that CMS has been listening to physicians’ concerns,” said AMA President Steven J. Stack, MD, said in a public statement. “In particular, it appears that CMS has made significant improvements by recasting the EHR Meaningful Use program and by reducing quality reporting burdens.”
The American Medical Informatics Association (AMIA) echoed these sentiments in its own remarks.
“While there is a tremendous amount of detail yet to understand, AMIA applauds CMS proposals that address the ‘all or nothing’ and threshold legacies of Meaningful Use,” stated Jeffery Smith, MPP, AMIA Vice President of Public Policy. “We also support the proposals that refocus requirements on those aspects of the program that are important, such as patient data access and patient engagement, care coordination and health information exchange. These changes will enable all stakeholders – providers and policymakers – to leverage program participation as a means to learn rather than simply grade.”
Still others remain skeptical, such as patient advocates.
In an op-ed recently published by the Society for Participatory Medicine, Health Quality Advisors, LLC President Michael Millenson explained that certain MACRA provisions could end up undermining patient engagement efforts.
For Millenson, the requirements for patient access mandating only one unique patient to satisfy objectives do not go far enough.
“Perhaps some pointed questions might be asked by attendees at this year’s Health Datapalooza, where a host of senior Obama administrations will provide preening perorations on their commitment to open data and patient empowerment,” he concluded. “If we in the patient community do not raise questions and objections to this critically important MACRA rule, you will definitely not believe what happens next.”
The public has 60 days from the official publishing of the MACRA proposed rule to comment on its provisions. Once that period has ended, CMS will evaluate feedback and the final rule will take shape and potentially alter many of these proposals.