CMS’ MACRA Final Rule

Incentive and Criteria for the New Physician Quality Payment Program

Earlier this year, CMS announced the Medicare and CHIP Reauthorization Act (MACRA) Proposed Rule repealing the Medicare Sustainable Growth Rate (SGR). MACRA aims to incentivize physicians’ transition to fee-for-value and into programs that place emphasis on clinical quality performance. Specifically, CMS has identified certain innovation-based programs referred to as Alternative Payment Models (APMs) that financially reward providers for their commitment to fee-for-value based programs.

In October, 2016 CMS finalized the MACRA rule, renaming the mandatory program the Quality Payment Program (QPP) and streamlining existing value and quality based programs, including the Physician Quality Reporting System (PQRS), the Value Modifier Program, and the Medicare Electronic Health Record (EHR) Incentive Program. These CMS value-based programs will now be aggregated and function as one new program under QPP. As such, providers will experience a Part-B adjustment through one of two tracks.

  1. Merit-Based Incentive Payment Systems (MIPS) –Providers not participating in a CMS qualified APM
  2. MIPS-APM & Advanced APM – Providers who voluntarily participate in a CMS qualified APM

To better prepare you for MACRA and QPP, we have highlighted key components of the program to consider.

Program Overview and Methodology

It is important to note that physicians, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists are all subject to the new QPP program and Part-B adjustment. However, providers that meet the “small practice exception” will be excluded from adjustment (for at least the 2019 adjustment year). Providers will be excluded from the new requirements if they meet a low-volume thresholds set at less than or equal to $30,000 in Medicare Part-B allowed charges or less than or equal to 100 Medicare patients.

As a result of AHN’s participation in a CMS fee-for-value payment program, all AHN providers will avoid a negative Part-B adjustment for the first performance year.

During the first Transition Year (adjustment year 2019/measurement year 2017) of the program, providers can pick their pace of participation. Providers can select to participate in one of four paths:

Full Participation

  • Report to MIPS for a full 90-day period and maximize the MIPS eligible clinician’s changes to quality for a positive adjustment
  • Report 6 Quality measures (including at least one outcome measure if available)
  • Report 4 medium-weighted or two high-weighted activities under Improvement Activities domains
  • Submission of the 5 required Advancing Care Information Performance measures

Partial Participation

  • Report to MIPS for a full 90-day period and report more than one quality measures, more than one improvement activity, or more than the required measures in the advancing care information performance category in order to avoid a negative MIPS payment and possibly receive a positive adjustment

No Adjustment

  • Report one measure in the quality performance category one activity in the impairment activities performance category; or report the required measures of the advancing care information performance category to avoid a negative adjustment

No Participation

  • Do not report any of the category domain measures and receive an automatic -4% Part-B adjustment During the program’s first adjustment year, clinicians will experience a Part-B rate adjustment ranging from -4 to 4 percent based on their scores in the three domains. By 2022, this up/down adjustment grows to 9 percent as noted in the table below.

Physician Payment Adjustments

Adjustment Year 2019 2020 2021 2022
Measurement Year 2017 2018 2019 2020

MIPS
Adjustment Range

-4% to 4% -5% to 5% -7% to 7% -9% to 9%

The 2017 measurement year rate adjustment methodology for MIPS participants is categorized by three domains – Quality, Improvement Activities and Advancing Care Information (ACI). As noted in the table below, the only reporting domain providers have responsibility for reporting is the Advancing Care Information (EHR adoption measures).

Category Performance Standards for 2017 Measurement Year

ACO MIPS-APM
Performance Category
Data Reporting Responsibility under an APM Program Domain Reporting Criteria Performance Category Weight
Quality
(PQRS quality submission)
Submitted by Clinician/Group Report 6 Quality measures (including at least one outcome measure if available) for a 90-day period 60%
Improvement Activities (Population Health Activities) Submitted by Clinician/Group Report 4 medium-weighted or two high-weighted activities under Improvement 15%
Advancing Care Information (ACI)
(EHR Adoption)
Submitted by Clinician/Group Submission of the 5 required Advancing Care Information Performance measures 25%

Summary

As a AHN member, we want to ensure you are fully prepared for CMS’ incentive and criteria under QPP. We will continue to update our members on the latest CMS developments and impact to your practice. Upcoming AHN ACO newsletters will review the program in more detail, however, should you have any immediate questions, please contact us at 210.297.1332 or use our contact form to get in touch with us.