The MACRA Basics
By Christine Queally Foisey
What Is MACRA?
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law on April 16, 2015. The legislation replaces the current Medicare reimbursement schedule, which is based on a fee-for-service model with a new pay-for-performance program that is focused on quality, value, and accountability. According to the Centers for Medicare and Medicaid Services, MACRA will implement a new payment structure that rewards health care providers for delivering better care instead of more service. MACRA makes the following three key changes to Medicare payment:
• It ends the current sustainable growth rate formula for determining Medicare payments for health care providers' services.
• MACRA implements a new model for reimbursing health care providers for giving better quality care as opposed to more quantity by establishing two tracks for payment — the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).
• It combines three existing quality reporting programs into one new system and adds an additional program into MIPS. The programs are the physician quality reporting system (PQRS), the value-based payment modifier (VBPM), meaningful use, and clinical practice improvement activities.
What Is MIPS?
MIPS is a new program that determines Medicare payment adjustments. It combines parts of the PQRS, the Value Modifier (VM or VBPM), and the Medicare EHR incentive program into one single program on which eligible professionals (EPs) will be measured. Contingent on a performance score, EPs may receive a payment bonus, a payment penalty, or no payment adjustment. The composite performance score comprises the following four categories:
• quality (PQRS/VM) (50%);
• resource use (10%);
• clinical practice improvement activities (15%); and
• meaningful use of certified EHR technology (25%).
Performance will be measured in these categories to obtain a "MIPS score" (0 to 100). The MIPS score can impact a provider's Medicare reimbursement in each payment year from -9% to +27% by 2022.
What Is an APM?
MACRA defines any of the following as an APM:
• an innovative payment model expanded under the Center for Medicare & Medicaid Innovation (CMMI), with the exception of Health Care Innovation Award recipients;
• a Medicare Shared Savings Program accountable care organization;
• a Medicare Health Care Quality Demonstration Program or Medicare Acute Care Episode Demonstration Program; or
• another demonstration program required by federal law.
For a provider to receive enhanced payment through a qualified APM, the APM must also meet the following requirements:
• use of quality measures comparable to measures under MIPS;
• use of a certified EHR technology; and
• assumes more than a "nominal financial risk" (which is undefined), or is a medical home expanded under the CMMI.
A physician receiving the designated percentage of Medicare payments or patients through a qualified, eligible APM based on the above requirements is considered a qualifying participant.
How Do I Know if I'm in MIPS or an APM?
Most physicians will utilize MIPS until more qualified, eligible APMs become available. However, physicians are able to switch payment models annually. According to the American Academy of Family Physicians, physicians interested in an APM model need to be prepared to start in the MIPS program.
What Is the Timeline for MACRA Implementation?
MIPS and APMs are in effect beginning in 2015 and continuing through 2021 and beyond. Some of the benchmarks include the following:
• 2016 through 2019 — MACRA establishes a 0.5% physician fee schedule update each year.
• January 2019 — Based on qualification and eligibility, physicians may enter the APM track or the MIPS track.
• 2020 through 2025 — Medicare physician fee schedule updates remain at 2019 levels with no updates.
What Should I Be Doing Now to Prepare for MACRA Implementation?
If you haven't reported data on quality measures through the PQRS or as part of meaningful use, start as soon as possible.
If you submitted quality data during the last calendar year, you should have access to your Quality and Resource Use Report. This report will help you understand your performance in terms of cost and quality so you can prioritize potential areas for improvement.
If your practice doesn't provide chronic care management (CCM) services, consider the cost-benefit opportunity for increasing revenue to support needed practice transformation or quality improvement projects. Medicare began paying for CCM codes on January 1, 2015.— Christine Queally Foisey is president and CEO of MedSafe.