In April, 2016, The Centers for Medicare and Medicaid Services (CMS) issued a Proposed Rule containing a new Quality Payment Program, which was created from the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 that repeals the Sustainable Growth Rate (SGR) reimbursement formula. This new reimbursement structure rewards physicians for the value of care they provide rather than the number of services rendered.
Currently, Medicare measures value and quality of care through multiple independent programs: the Physician Quality Reporting Systems (PQRS), Value Modifier (VM) program, and the Electronic Health Record (EHR) Incentive program. The proposed rule streamlines these programs - and an added component for Clinical Practice Improvement Activities - into one platform, the new Merit-based Incentive Payment System (MIPS). A physician or group’s performance across four performance categories will produce a composite score (CPS) that will be compared with that the national average MIPS CPS (called the ‘performance threshold’) to determine eligibility for bonuses or penalties.
The Quality Payment Program contains an alternate path in which providers may qualify to participate, Advanced Alternative Payment Models (APMs). APMs are basically innovative care models such as payment bundling, accountable care organizations, etc. As CMS anticipates that the APMs would apply to a comparatively small segment of clinicians in the beginning, most physicians are expected to report through MIPS the first year.
The Proposed Rule has the first MIPS performance period set to begin January 1, 2017, with the corresponding payment adjustments to be applied in 2019. As the Final Rule is not expected to be published until November 1, 2016, there have been numerous requests for a delay, including from U.S. Representative Phil Roe, MD (R-TN), MACRA co-author who pushed for at least a six-month delay in performance metric reporting by physicians.
In response, CMS recently announced it will allow practices to choose the level and pace at which they will comply with the rules through four options:
1. Testing the Quality Payment Program
As long as a physician submits some quality data from after January 1, 2017, to the payment program, a negative payment adjustment will be avoided. According to Andy Slavitt, CMS’ acting administrator, the intent of this option is to ensure systems are working appropriately and providers can prepare for wider participation in 2018 and 2019.
2. Participating for a partial calendar year
Physicians submit quality data for a limited period meaning the first performance period could begin later than January 1, 2017, and the provider could still qualify for a small positive payment adjustment.
3. Participating for a full calendar year
Providers submit quality data for the year, beginning January 1, 2017.
4. Participating in an Advanced APM in 2017
Instead of reporting quality, the physician participates by joining an Advanced (APM) such as Medicare Shared Savings Track 2 or 3 next year.
There were over 3900 responses to the proposed rule submitted during the open comment period that closed on June 27, 2016. Clinicians continue to await the final details expected later this year. Per Slavitt, the federal agency has talked to thousands of physicians and clinicians across the country. “Universally, the clinician community wants a system that begins and ends with what’s right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016.”